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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage (CPT code 21121 (genioplasty; sliding osteotomy, single piece); CPT code 21139 (reduction forehead; contouring and setback of anterior frontal sinus wall), CPT code 13152 (repair of earlobe) x 2; CPT code 11406 (excisions, benign lesion including margins, except skin tag, trunk, arm or legs; excised diameter greater than 4.0 cm (dog ear removal) x 2) for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that Based on the entirety of the medical documentation provided for this review, a portion of the requested services is medically necessary and are reconstructive in nature. Cosmetic surgery is based on improving on relatively normal structures and reconstructive surgery is based on approximating a more normal appearance or relieving a functional deficit. The medical literature supports facial feminization surgery which can include forehead remodeling, rhinoplasty, thyroid chondroplasty, and voice alteration procedures for treatment of gender dysphoria. In this patients case, the significant prominence of the lower forehead appears outside the normal structures typical for a female. With respect to the forehead, the patient is noted to have a significantly abnormal appearance for a female. However, this is not the case for the chin or earlobes. Based on the submitted documentation, the patient has findings of the chin and earlobes which are more consistent with a relatively normal female appearance and not gender specific. In sum, CPT code 21139 (reduction forehead; contouring and setback of anterior frontal sinus wall) is medically necessary for treatment of this patients gender dysphoria. However, there is a lack of documentation establishing the medical necessity of the requested services other than for the forehead reshaping. With regard to whether the requested services are considered reconstructive in nature, there is a wide spectrum of facial appearances that can be consistent with typical female appearances. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Thus, there can be indications for surgical treatment to establish a female appearance. However, this should be considered on a case by case basis. For this patient, there has been insufficient justification for the requested procedures, except for the forehead. The patient has a relatively normal appearance that is not necessarily gender specific for the earlobes and chin.  This is not the case for the forehead. The patients forehead appears outside the norm for typical female gender. Therefore, the requested CPT code 21139 (reduction forehead; contouring and setback of anterior frontal sinus wall) is reconstructive in nature. The requested services for the chin and earlobes are consistent with aesthetic improvement, addressing appearance concerns and not specific gender-related abnormalities. Thus, CPT code 21121 (genioplasty; sliding osteotomy, single piece); CPT code 13152 (repair of earlobe) x 2; CPT code 11406 (excisions, benign lesion including margins, except skin tag, trunk, arm or legs; excised diameter greater than 4.0 cm (dog ear removal) x 2 are not reconstructive in nature for the treatment of this patients gender dysphoria. Final Result: The reviewer determined that a portion of the requested services are medically necessary and are reconstructive for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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.