Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gender dysphoria

Treatment: Tracheal shave surgery

The insurer denied coverage for tracheal shave surgery

The denial is upheld

This case involves a transgender who was being recommended for tracheal shave as an initial gender affirming surgery. The patient was seeing a private voice feminization coach and endorsed vocal fatigue when trying to modify the sound of her voice. The patient was being recommended for tracheal shave to reduce the thyroid cartilage prominence. A progress notes stated that the patient was just beginning her transition, which started with hormone replacement therapy. She was working with a private voice feminization coach to address her pitch, elevation, color, and resonance. On examination, there was tension with phonation in the thyrohyoid space or tongue base with prominent thyroid cartilage notch and a thin neck. A 70-degree rigid endoscopy with stroboscope was performed to assess the oropharynx and surrounding structures. The proposed surgery was denied with the final adverse determination letter stating that the plan does not cover cosmetic procedures and was related to reconstructive surgery from trauma, infection, or diseases of the involved part, or because of a congenital disease or anomaly, which has resulted in a functional defect. Prior appeal letters indicated that the patient was diagnosed with gender dysphoria and expressed persistent desire for tracheal shave surgery. The goals of surgery were to be able to live more fully in a gender role congruent with her affirmed gender. It was believed that surgery was the best way to achieve these goals and to further alleviate her gender dysphoria. The physician stated the patient was mentally stable and had fully explore the risks, benefits, and alternatives of the surgery. 

The healthcare policy has indicated that certain ancillary procedures, including but not limited to the following are considered cosmetic and not medically necessary, when performed as part of a surgical treatment for gender dysphoria. This includes trachea shave. Medical literature states that chondrolaryngoplasty, or "tracheal shaving," is a cosmetic procedure designed to reduce the prominence of the thyroid cartilage. Records indicate the patient was medically stable, understanding the risks and benefits of the surgery, although she reported significant anxiety, depression, and distress due to her experience of dysphoria. While the patient may be a suitable candidate for the procedure given her understanding of the risks and benefits of surgery, and with the indications that this would reportedly help with her gender dysphoria, this is considered a cosmetic procedure in general. For all other gender reassignment procedures, patients are required to have written psychological assessment from at least 2 qualified behavioral health providers experienced in treating gender dysphoria, have independently assessed the individual, and have included all of the following to include that the member is capable to make a fully informed decision and has consented for treatment, is at least 18 years of age, has any significant medical or mental health concerns reasonably well controlled, has completed least 12 months of successful continuous full-time real-life experience in the desired gender, and has completed 12 months of continuous cross-sex hormone therapy appropriate for the desired gender (unless medically contraindicated). The records provided for the review did not include that the patient was assessed by two qualified mental health specialists nor was their confirmation that the patient completed at least 12 months of successful continuous full-time real-life experience in the desired gender. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for tracheal shave surgery is upheld. Medical Necessity is not substantiated.