Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Gender dysphoria
Treatment: Facial surgery - procedure codes: 21138, 67900, 30410 & 15828
The insurer denied coverage for facial surgery - procedure codes: 21138, 67900, 30410 & 15828
The denial is modified

According to the documentation submitted, this is a patient with a history of gender dysphoria. The patient presented for facial feminization surgery; The patient had Chondrolaryngoplasty (Tracheal Shave), Scalp advancement, forehead and orbital cranioplasty, brow lift, rhinoplasty, jaw / chin contouring, neck liposuction, and an energy skin tightening facelift. 

The insurer has denied coverage for facial surgery - procedure codes: 21138, 67900, 30410 and 15828 as not medically necessary.

 
The health plan acted correctly in denying code 15828 but not in denying codes 21138, 30410 and 67900.  

Code 15828 was not medically necessary. A facelift is a procedure that treats facial aging. Facial skin laxity is not a female or male characteristic but rather a characteristic of an aging face. Facelift provides a more youthful appearance rather than a specifically female or male appearance. As such, facelift primarily improves appearance by correcting the sequelae of facial aging and therefore is a cosmetic procedure rather than a gender affirming procedure.

Codes 21128, 30410 and 67900 were medically necessary. The surgeon's preoperative notes document a masculine appearing brow with a heavy ptotic brow and prominent frontal bone projection as well as a masculine appearing nose with thick skin and a strong dorsal hump. These are masculine appearing facial features that were contributing to the patient's gender dysphoria. According to the relevant surgical sections of World Professional Association for Transgender Health (WPATH) guidelines, 8th edition:

13.6- We suggest health care professionals consider gender-affirming genital procedures for eligible transgender and gender diverse adults seeking these interventions when there is evidence the individual has been stable on their current treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated).

13.7- We recommend surgeons consider gender-affirming surgical interventions for eligible transgender and gender diverse adolescents when there is evidence a multidisciplinary approach that includes mental health and medical professionals has been involved in the decision-making process.

In this case, there is evidence of a multidisciplinary approach that included mental health and medical professionals involved in the decision-making process. The patient's therapists and surgeon recommend facial feminization surgery as a key component of treatment for gender dysphoria. In addition, there is evidence the individual has been stable on their current treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated). The patient has lived as a female for years and has been on hormone therapy. This patient has anxiety, depression and dysphoria that her mental health providers attribute directly to the incongruence of her facial appearance with her assigned sex. She is mistaken for male, which worsens her dysphoria. 

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for facial surgery - procedure codes: 21138, 67900, 30410 is substantiated. The health care plan did act reasonably with regard to procedure code 15828. The medical necessity for procedure 15828 is not substantiated.