Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for bilateral mastectomy with male chest reconstruction.At issue is whether bilateral mastectomy with male chest reconstruction is medically necessary to treat the enrollees condition (gender dysphoria) as defined in Health and Safety Code section 1374.72(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.The World Professional Association for Transgender Health (WPATH) supports chest surgery for transmasculine minors as a medically necessary treatment for gender dysphoria. Chest surgery in female-to-male patients could be carried out earlier than 18, 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 adolescents specific clinical situation and goals for gender identity expression. chest surgery is an effective treatment of gender dysphoria in minors. Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age. In this case, the patient has lived stably as male, and has been on testosterone for over a year. Additionally, the patients mental health, medical, and surgical providers agree that chest surgery would help treat the patients gender dysphoria. Thus, the requested bilateral mastectomy with male chest reconstruction is medically necessary to treat the patients medical condition. Specifically, the requested bilateral mastectomy with male chest reconstructions is in accordance with the generally accepted standards of mental health and substance use disorder care. The requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. Additionally, the requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.Final Result: The reviewer determined that the requested service is 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 with expertise in transgender medicine 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.