Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gender dysphoria

Treatment: Facial reconstruction surgery (facial feminization surgery; procedure codes 21127, 21122, 21125, 15824, 21256, and 21139)

The insurer is denied coverage for continued inpatient hospital admission.

The denial is upheld. 

This is a transgender female. She is currently under hormone and depression treatment for the last three years. Facial feminization surgery is requested. Although these surgeries do not require referral by mental health professionals, such professionals can play an important role in assisting clients in making a fully informed decision about the timing and implications of such procedures in the context of the social transition.

Although most of these procedures are generally labeled 'purely aesthetic,' these same operations in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a given patient's condition and life situation. This ambiguity reflects reality in clinical situations, and allows for individual decisions as to the need and desirability of these procedures." The records do not document any unique situations. These are aesthetic procedures to make the patient more attractive in her new gender.

According to a study by Ainsworth and Spiegel: "There was no statistically significant difference in the mental health-related quality of life among transgendered women who had gender reassignment surgery (GRS), facial feminization surgery (FFS), or both." Although the study showed that transgender women without surgical intervention had lower mental health related quality of life compared to transgender women, women who had both FFS and GRS did not have improved mental health outcomes compared to those who had GRS alone. 

According to a systematic review of the literature on facial feminization, "Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction."  

Morrison, et al., confirms that outcome reporting on the benefits of FFS has been disparate and non-standardized. The mental health benefits of facial feminization and voice surgery have not been rigorously studied with validated outcome measurements. 

A 2018 meta-analysis concluded: "Evidence suggests that transgender people have lower QoL than the general population. Some evidence suggests that QoL improves post-treatment. Better quality studies that include clearly defined transgender populations, divided by stage of gender affirming treatment and with appropriate matched control groups are needed to draw firmer conclusions."   For this specific patient, photos showing facial features inconsistent with female gender are not provided for review. In addition, peer literature does not clearly show improvements in anxiety or depression in transgender women treated with facial feminization. 

According to the World Professional Association for Transgender Health (WPATH) guidelines, pages 63-64: "Other surgeries for assisting in body feminization include reduction thyroid chondroplasty (reduction of the Adam's apple), voice modification surgery, suction-assisted lipoplasty (contour modeling) of the waist, rhinoplasty (nose correction), facial bone reduction, face-lift, and blepharoplasty (rejuvenation of the eyelid). Other surgeries for assisting in body masculinization include liposuction, lipofilling, and pectoral implants. Voice surgery to obtain a deeper voice is rare but may be recommended in some cases, such as when hormone therapy has been ineffective."

The requested procedures are not medically necessary. The health plan acted reasonably and with sound medical judgment. The procedures will primarily change appearance and are not required for health or function.

Based on the above, the medical necessity for facial reconstruction surgery (facial feminization surgery; procedure codes 21127, 21122, 21125, 15824, 21256, and 21139) is not substantiated.  The insurer's denial is upheld.