Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Standard Review A transgender female enrollee has requested authorization and coverage for facial feminization surgeries (CPT code 21137, reduction of forehead, contouring only; CPT code 67900, repair of brow ptosis  (supraciliary, mid-forehead or coronal approach); CPT code 15770, autologous fat transfer to face; CPT code 21198, jaw taper; and CPT code 40799, lip lift). The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature for treatment of the enrollees gender dysphoria. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Nature of Statutory Criteria/Case Summary: Based on the entirety of the medical documentation provided for this review, including review of the photographs, the requested services are not medically necessary in this clinical setting. Photographs show evidence of a relatively normal appearing female face for the patients age. There appears to be minimal to mild brow ptosis, minimal frontal bone projection and overall signs of facial aging for her age. There was a lack of detailed examination documented in the medical records. In addition, the photographs do not show evidence of a masculine appearance of the brows, forehead, chin and lips. Instead, the photographs indicate that a more female appearance with signs of facial aging consistent with the patients age. These findings are relatively gender neutral or more female in appearance. Although facial feminization surgery can be satisfying to the patient, the requested services should be considered treatment of relatively normal structures for her age and gender. Therefore, this patients facial features are not atypical for a female appearance and are consistent in the spectrum of typical female appearances. In sum, the facial feminization surgeries (CPT code 21137, reduction of forehead, contouring only; CPT code 67900, repair of brow ptosis  (supraciliary, mid-forehead or coronal approach); CPT code 15770, autologous fat transfer to face; CPT code 21198, jaw taper; and CPT code 40799, lip lift) are not medically necessary for treatment of this patients gender dysphoria. With regard to whether the requested services are considered reconstructive in nature, it must first be established if the patients facial features constitute an abnormal structure of the body. There is a wide spectrum of facial appearances that can be consistent with typical female appearances. Based upon the documentation provided, the appearance of the patients face including the forehead, brow, jaw and lip is not necessarily gender specific and would not be considered abnormal for the female gender. For these reasons, the facial feminization surgeries (CPT code 21137, reduction of forehead, contouring only; CPT code 67900, repair of brow ptosis (supraciliary, mid-forehead or coronal approach); CPT code 15770, autologous fat transfer to face; CPT code 21198, jaw taper; and CPT code 40799, lip lift) are not reconstructive in nature for the treatment of this patients gender dysphoria. Final Result: The reviewer determined that the requested services are not medically necessary and are not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.