Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to pre-approve six visits. We decided that the Plan does not have to pre-approve
the remaining six requested visits.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan says that there
is no medical disorder that has resulted in a communication deficit that necessitates active therapy.
We decided that the Plan has to pre-approve six visits.
The Plan follows Medicare rules. Medicare rules say that the plan pays for medically necessary outpatient
therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request. Our reviewer says that six of the requested visits are
medically reasonable and necessary. Our physician reviewer found that voice feminizing therapy involves
treatments to help transgender women (male to female) adapt their voices, resulting in communication patterns
that match their gender identity. Treatments can help change vocal characteristics, such as pitch and intonation,
and nonverbal communication patterns, such as gestures and facial expressions. A prescribed course of voice
therapy is medically necessary when provided by a certified speech-language pathologist for a significant voice
disorder. Speech therapy can be included in the plan of care when treating individuals undergoing transgender
reassignment. The enrollee Speech therapy can be included in the plan of care when treating individuals
undergoing transgender reassignment. The enrollee would be unable to achieve the stated goals without the
skilled therapy services being requested. Six visits to start is reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of six visits have been met. Therefore, we decided that the Plan has to pre-approve
six visits.
We also decided that the Plan does not have to pre-approve the remaining six requested visits.
The Plan follows Medicare rules. Medicare rules say that the plan pays for medically necessary outpatient
therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request for the remaining six visits. Our reviewer says that
these last six visits are not medically reasonable or necessary. Our physician reviewer found that the number of
treatments being requested is excessive as 12 treatments are being requested. A reassessment after completing
6 treatment sessions would be expected before requesting additional skilled speech therapy services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the remaining six requested visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve the remaining six requested visits.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.