Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient presents with a history of gender dysphoria, anxiety and depression. The records document that the patient is status post orchiectomy and has received treatment with hormone therapy. Per the documentation, an abnormal chest size and shape was noted for the patients body-mass index. Per the submitted documentation, the patient is frequently mistaken for a female in public. The documentation noted that the patient has been wearing a chest binder 24 hours a day, seven days a week (including during sleep) for several years. This appears to have resulted in permanent bruising and rib cage disfigurement. The patient has been unable to engage in healthy levels of physical activity and exercise, especially in warmer weather, due to the chest size and shape. The patient has been unable to maintain adequate social relationships necessary for minimal mental health. The provider noted that the patient has been unable to establish romantic relationships due to his shame and fear. Per the documentation, the patient had pursued alternatives to surgery, including adjustments to hormone therapy and upper-body-focused weight lifting to reduce breast size, without success. The patient has requested coverage for bilateral mastectomy, nipple reconstruction, and full thickness graft. The Health Plan denied this request and reported the requested services are not medically necessary for treatment of this patient. At issue in this case is whether bilateral mastectomy, nipple reconstruction, and full thickness graft are medically necessary for the treatment of the patients medical condition. The patient has documented history of gender dysphoria and has received treatment to transition from male to female including hormone therapy and orchiectomy. The patient did not find that gender dysphoria was resolved and currently identifies as a transgender individual. The patient continues to have gender dysphoria and wishes to undergo chest reconstruction to remove any female chest characteristics. Mastectomy for transgender men is necessary for many in order to resolve gender dysphoria. When bilateral (double-incision) mastectomy is performed, nipple grafts are a necessary component of the surgery. When keyhole (periareolar incision) is performed, nipple grafts are less likely necessary, but may be required in some cases. Chest reconstruction surgery in combination with hormone therapy has been shown to be more effective in alleviating gender dysphoria than hormone therapy alone. Quality of life is higher among transgender men who have undergone chest reconstruction than those who have not. The medical evidence supports the requested services in this clinical setting. Therefore, the requested bilateral mastectomy, nipple reconstruction, and full thickness graft are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 a similar medical condition.