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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for bilateral mammoplasty augmentation with prosthetic implant, tissue graft, and suction assisted trunk lipectomy. The enrollee has been in counseling for gender dysphoria and began hormone therapy for gender change.  She is hormonally a female with stable hormone levels.  Her psychiatrist indicates she has successfully taken the steps required for gender confirmation surgery (GCS) and is mentally stable to continue hormone treatment and to move forward with the vaginoplasty/GCS.  Feminizing vaginoplasty, breast augmentation, laryngoplasty, facial feminization surgery and fat transfer body contouring are recommended. The counselor reports she was already a well-adjusted trans-female when she entered therapy. The enrollee identifies as a female and has revealed this to family, friends, and support network.  She has been living as a female, has legally changed her name, and has used cross-sex hormones continuously and responsibly for over five years.  The provider recommends the requested surgical procedures for the purpose of physical gender transition from male to female to further alleviate severe psychological symptoms related to increased gender dysphoria resulting from a masculine chest. Breast augmentation documentation for male-to-female transfer enrollees should include persistent gender dysphoria. The enrollee should have the capacity to make a fully informed decision and provide consent for treatment.  The enrollee should have attained the age of majority. Significant medical or mental health concerns must be reasonably well controlled.  A 12-month course of feminizing hormone therapy prior to augmentation is recommended for male-to-female enrollees; this maximizes breast growth and optimizes surgical results. Records indicate gender dysphoria since childhood. The enrollee meets guidelines of fully informed decision-making, age of majority and lack of significant medical or mental health concerns. The records support the enrollee is mentally appropriate to undergo the surgical intervention as the enrollee has been living as a female and is comfortable as such.  The requested procedures are necessary for the enrollee to complete the physical transition and to provide resolution of gender dysphoria issues. Records indicate the enrollee is emotionally prepared to take the next step of the process, including bilateral mammoplasty augmentation with prosthetic implant, tissue graft, and suction assisted trunk lipectomy. This enrollee is an appropriate candidate for these procedures.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent psychiatry 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 similar medical condition.