Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gender Dysphoria
Treatment: Surgical Services
The health plan denied the requested service of breast removal and nipple reconstruction surgery as not medically necessary. The reviewer has overturned the health plan's determination in whole. 

This is a female to male (FtM) transgender person, with gender dysphoria. He has been using a binder. He has depression, anxiety and inattention symptoms. Neuropsychological assessment was reviewed. His psychological conditions are controlled. Letters of support were reviewed. Overturn in whole. The requested health service/treatment of Breast removal and nipple reconstruction surgery is medically necessary for this patient at this time. For individuals seeking care for gender dysphoria, a variety of therapeutic options can be considered: medical, psychological, and surgical. Specific to female to male (FtM) transgender patients, medical therapy with hormones, if indicated, are prescribed to create a more masculine appearance. In FtM patients, the following physical changes are expected to occur: deepened voice, clitoral enlargement (variable), growth in facial and body hair, cessation of menses, atrophy of breast tissue, increased libido, and decreased percentage of body fat compared to muscle mass (Coleman et al). Testosterone and gonadotropin-releasing hormone (GnRH) analogs are used to achieve masculinization that will induce physical changes that are more congruent with a patient's gender identity. (Spack). According to World Professional Association for Transgender Health (WPATH) guidelines, "There is no clear distinction between what is purely reconstructive and what is purely cosmetic...most professionals agree that genital surgery and mastectomy cannot be considered purely cosmetic." For chest contouring "top surgery," there are a variety of different variations of the subcutaneous mastectomy described, with or without free nipple grafting (Frederick et al, Bluebond-Langner et al, Safa et al). The WPATH criteria for mastectomy (one referral necessary from a qualified mental health professional) [met, at least one referral letter was enclosed] is as follows: 1. Persistent, well-documented gender dysphoria [met, gender dysphoria is documented]; 2. Capacity to make a fully informed decision and to consent for treatment [not applicable, see criteria below for adolescents]; 3. Age of majority in a given country (18 years of age in the USA) [not applicable, see criteria below for adolescents]; 4. If significant medical or mental health concerns are present, they must be reasonably well controlled [met, the medical/mental health concerns present are reasonably well controlled]. According to WPATH guidelines for adolescents, any surgery is an irreversible intervention, and as such must be treated very carefully, "Chest surgery in FtM patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent's specific clinical situation and goals for gender identity expression." This patient is under 18 years of age but has lived in the male gender role for at least 1 year. He has also been on masculinizing hormones. This patient meets WPATH guidelines for mastectomy, therefore the requested surgery is medically necessary.