Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial feminization surgery. The Health Plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees gender dysphoria.At issue in this case is whether the requested facial feminization surgery is medically necessary for treatment of the enrollees medical condition.Facial feminization surgery would provide reconstructive surgical services for an abnormality as a result of the disorder of gender dysphoria. The outcome of reconstructive surgery would be enhancement of psychological and social functioning. The patient has a documented history of gender dysphoria and is currently on cross gender hormone therapy. In addition she has already had chest surgery/breast augmentation, as well as documentation of castration in the surgical progress note dated 4/24/2018.Guidance for the medical necessity of FFS was found in two reviews from WPATH and the Transgender Law Center. On the matter of medical necessity and the classification of FFS as reconstructive surgery, World Professional Association for Transgender Health (WPATH) states that, In addition to hormonal balancing, medically necessary gender affirming/confirming surgical procedures are described in section XI of the Standards of Care. These procedures include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary; genital reconstruction by various techniques which must be appropriate to each patient, including, for example, skin flap hair removal, scrotoplasty, and penile and testicular prostheses, as necessary; facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient. The medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. The Transgender Medicine Model NCD Working Group, Transgender Law Center in their review of evidence for FFS state that, Other surgeries or procedures that may be necessary to resolve gender dysphoria and allow transgender women to navigate the world as women include  reconstructive facial feminization surgeryThese procedures are not cosmetic, but rather serve a primarily reconstructive purpose by allowing transgender women whose overall physical appearance otherwise prevents them from being perceived as female.Based on the documented history of gender dysphoria and evidence of the medical necessity of facial feminization surgery, the facial feminization surgery is medically necessary.Final Result: The reviewer determined that the requested surgery 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 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.