Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the following facial feminization surgeries: reduction forehead; contouring and setback, anterior frontal sinus wall; supraciliary/mid-forehead/coronal approach; genioplasty; sliding osteotomies; malar augmentation; prosthetic material; adjacent tissue transfer, forehead/cheek/chin/mouth/neck/axillae/genitalia/hands/face (scalp advancement); osteoplasty, facial bones, reduction; reconstruction, mandibular rami and/or body, sagittal split without internal rigid fixation; repair lip, full thickness; up to half vertical height; tissue grafts; stereotactic computer-assisted (navigational) procedure; cranial; extradural; suction assisted lipectomy; head and neck; tracheal shave.  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.Findings:  The physician reviewer found that the submitted documentation and the photographs support the requested surgeries in this clinical setting. The photographs demonstrate that the patient has masculine features, which do not allow her to be recognized as a female. The photographs show a masculine appearing forehead, that is overly prominent, and a high riding hairline, which is typical for a male pattern anterior hairline. The patients mandible/cheek (malar areas) and upper lip are also masculine appearing. The mandibles in females are narrower with a smaller chin point (not broad) and the mandibular angle has a smooth contour (not square). The cheeks in a female are typically more prominent with higher cheekbones. The upper lip of a female is shorter with increased incisor show of the upper teeth. The patients trachea is also masculine appearing. In addition to the photographic evidence provided, the submitted documentation includes recommendations from the patients mental health providers which indicate the requested procedures are necessary to improve the patients gender dysphoria. Accordingly, the aforementioned facial feminization surgeries are medically necessary for the treatment of this patients gender dysphoria.With regard to whether the requested services are considered reconstructive in nature, the submitted documentation demonstrates that the patients facial presentation constitutes an abnormal body structure caused by her gender dysphoria and are considered a developmental abnormality. The requested surgeries will create a normal appearance to the extent possible and are likely to result in more than a minimal improvement in the patient's appearance. Therefore, the aforementioned facial feminization surgeries are reconstructive in nature.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery with expertise in transgender 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.