Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteoplasty, facial bones; reduction (21209), 
genioplasty; augmentation (21120, 21122), forehead reduction (21137, 21139), a larynx surgery procedure 
(31599), adjacent tissue transfer or rearrangement of the eyelids, nose, ears and/or lips (14060), and grafting of 
autologous fat harvested by liposuction to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and or feet 
(15773, 15774). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that cosmetic surgery or expenses incurred in connection with 
such surgery is not covered. Additionally, Effective August 30, 2016, CMS determined that no national 
coverage determination (NCD) is appropriate at this time for gender reassignment surgery for Medicare 
beneficiaries with gender dysphoria. Any other relevant statutory requirements, will continue to be made by the 
local Medicare Administrative Contractors (MACs) on a case-by-case basis. 
 
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 to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there has been no documentation provided that indicates the requested surgeries at issue in 
this case meet all Medicare criteria to be considered medically reasonable and necessary. Medicare rules say 
that the Centers for Medicare & Medicaid Coverage (CMS) conducted a National Coverage Analysis that 
focused on the topic of gender reassignment surgery. Effective August 30, 2016, after examining the medical 
evidence, CMS determined that no national coverage determination (NCD) is appropriate at this time for 
gender reassignment surgery for Medicare beneficiaries with gender dysphoria. In the absence of an NCD, 
coverage determinations for gender reassignment surgery, under section 1862(a)(1)(A) of the Social Security 
Act (the Act) and any other relevant statutory requirements, will continue to be made by the local Medicare 
Administrative Contractors (MACs) on a case-by-case basis. Additionally, Medicare rules say that cosmetic 
surgery or expenses incurred in connection with such surgery are not covered. The provided records in this case 
do not document that the requested surgeries are reasonable and necessary for the diagnosis or treatment of 
illness or injury or to improve the functioning of a malformed body member as required by Social Security Act, 
Section 1862 (a)(1)(A). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an osteoplasty, facial bones; reduction (21209), genioplasty; augmentation (21120, 21122), 
forehead reduction (21137, 21139), a larynx surgery procedure (31599), adjacent tissue transfer or 
rearrangement of the eyelids, nose, ears and/or lips (14060), and grafting of autologous fat harvested by 
liposuction to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and or feet (15773, 15774).