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

Nature of Statutory Criteria/Case Summary:An enrollee has requested facial feminization treatment of the enrollees gender dysphoria. Based on the entirety of the medical documentation provided for this review, the requested services are not medically necessary and are not reconstructive in nature. The medical literature supports facial feminization surgery which can include forehead remodeling, rhinoplasty, thyroid chondroplasty, and voice alteration procedures for treatment of gender dysphoria. However, the submitted documentation does not support a functional deficit in this patients case, for each of the requested services. The photographs show evidence of mild brow ptosis bilaterally, but no evidence of significant brow or lower forehead prominence, mild prominent ears, signs of facial aging of the lower face and neck. The photographs also indicate a relatively normal appearing nose, relatively normal lips and no evidence of chin projection. In the documentation provided, there is insufficient evidence that supports a functional deficit is present that would require surgical intervention. With respect to the nose, the patients appearance could be considered relatively normal for a female and not gender specific.  With respect to the upper eyelids, there is some evidence of mild dermatochalasis, but it would not be considered gender specific.  With respect to the forehead and brow, there is evidence of mild brow ptosis, but this can be an expected finding given the patients age and gender as a female.  Thus, this is a relatively normal appearance for a female.  There is no evidence of brow/lower forehead prominence to suggest a gender-related abnormality. With respect to the lower face, neck and chin, the patients appearance is more consistent with signs of facial aging and not gender specific.  With respect to the upper lip, her appearance is more consistent with a relatively normal lip for her age and gender. Craniofacial contouring, in this patients case, is also not consistent with treatment of a specific gender related abnormality.  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. In this patients case, the facial features which this patient is seeking to address are consistent with a female appearance and are not considered abnormal. In this patients case, her appearance is consistent within the spectrum of possible or what is typical of female appearances. As such, the requested services should be considered treatment of relatively normal structures for her age and gender. Overall, the clinical documentation is insufficient to support the requested services. Instead, the requested services are consistent with aesthetic improvement, addressing appearance concerns and not specific gender-related abnormalities. Thus, the requested services would be considered cosmetic enhancements and are not required to address an abnormal structure.Findings:The physician reviewer found that the requested services are not medically necessary and are not reconstructive for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.