Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial feminization surgeries included repair of brow ptosis (brow lift); adjacent tissue transfer or rearrangement (hairline advancement); reduction forehead; contouring only; lip lift; fat graft to lips; and autologous fat transfer to face. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria and are not reconstructive in nature.Based on documentation provided for this review including review of the photographs, there is support for a portion of the requested services in this clinical setting. The patient is documented to have gender dysphoria. The examination documented by the provider and the photographs show evidence of a masculine appearing anterior hairline. However, the brows, forehead, lips and midface are not clearly masculine and could be consistent with a normal female appearance. The photographs show evidence of a gender neutral brow, forehead, lips and midface. Accordingly, the patients facial appearance is consistent within the spectrum of the female gender except for her anterior hairline. As such, a portion of the requested services is medically necessary for treatment of this patients gender dysphoria. Specifically, the adjacent tissue transfer or rearrangement (hairline advancement) is medically necessary for the treatment of this patients gender dysphoria. However, facial feminization surgeries included repair of brow ptosis (brow lift); reduction forehead; contouring only; lip lift; fat graft to lips; autologous fat transfer to face are relatively gender neutral or more female in appearance; therefore, they are not atypical for a female appearance. Overall, the clinical documentation is insufficient to support the medical necessity of the requested services except for the anterior hairline advancement.With regard to whether the requested services are considered reconstructive in nature, the submitted documentation demonstrates that a portion of the patients condition constitutes an abnormal body structure. The records support that this patients anterior hairline constitutes an abnormal body structure for the female gender due to a developmental abnormality, specifically, her gender dysphoria. However, the patients facial presentation as to repair of brow ptosis (brow lift); reduction forehead; contouring only; lip lift; fat graft to lips; autologous fat transfer to face do not constitute abnormal body structures. There is a wide spectrum of facial appearances that can be consistent with typical female appearances. The patients brows, forehead, lips and midface are not clearly masculine and could be consistent with a normal female appearance. In this patients case, the requested surgery of adjacent tissue transfer or rearrangement (hairline advancement) would create a more normal female appearance of her hairline to the extent possible. Additionally, the requested hairline advancement would provide more than a minimal improvement in the appearance of this patient. In sum, treatment of the masculine anterior hairline - adjacent tissue transfer or rearrangement (hairline advancement) is reconstructive in nature; however, the repair of brow ptosis (brow lift); reduction forehead; contouring only; lip lift; fat graft to lips; and autologous fat transfer to face are not considered reconstructive in nature.Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be partially overturned. Specially, the requested surgery of adjacent tissue transfer or rearrangement (hairline advancement) is medically necessary for the treatment of this patients gender dysphoria and is reconstructive in nature. Credentials/Qualifications: The reviewer is board certified in plastic surgery 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.