Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender Dysphoria, Male to female.
Treatment: Facial feminization surgery and surgery to tighten the skin of the face and remove fat from the neck.
The insurer denied: facial feminization surgery and surgery to tighten the skin of the face and remove fat from the neck.
The denial is partially overturned.

The patient is a male to female transgender patient who is under consideration for facial feminization surgery. The patient has been on hormone therapy for 2 years and has had gender affirming genital surgery/vaginoplasty as well as buccal fat pad removal. At the examination the forehead was elongated, supraorbital fullness was present, frontal sinus was convex and breast tissue was 15 centimeters (cm) wide. The subject under review is the medical necessity for the facial feminization surgery and surgery to tighten the skin of the face and remove fat from the neck.

The requested facial feminization surgery and surgery to tighten the skin of the face and remove fat from the neck is medically necessary, in part.

World Professional Association for Transgender Health (WPATH) version 7 standards are specific and clear for gender affirming genital surgery and to some degree for gender affirming chest surgery but only state that opinions diverge on the medical necessity of facial procedures. Their 12/21/2016 update is also limited with respect to facial feminization, which it states is "often of greater practical significance in the patient's daily life than reconstruction of the genitals". WPATH version 8 is less helpful. Facial feminization surgery seems to be safe and satisfactory for patients. Patients report high satisfaction and after facial feminization procedures but so do the majority of patients undergoing cosmetic/rejuvenating surgery. There are no national guidelines, criteria or peer reviewed articles stating who should or should not get specific procedures beyond frontal bone burring vs. setback.

Submitted photos show ethnic brow ptosis, epicanthal folds, high cheek bones, flattened short dorsum, retruded columella, greater than 110 degree nasolabial angle and parentheses nasal tip. There is also a high forehead, frontal bossing creating the appearance of a deep radix and dark shadows over the eye sockets, minimal nasolabial folds, microgenia with mentalis strain, a deep labiomental groove and small mandible that contribute to an obtuse neck angle. The thyroid cartilage is only visible/prominent on neck extension.

The only non-ethnic masculinizing features in these photos are the orbital rim projection and thyroid cartilage prominence as high foreheads can be found in both sexes. Brow ptosis and submental fat are not gender confirming traits. Therefore, the following procedures are medically necessary to treat this patient's gender dysphoria by achieving a feminine appearance: 21256 orbital reconstructions, 21172 superolateral orbital rim recon, 21139 forehead setback and 31899 tracheal shave.

The following procedures are not medically necessary to treat the patient's gender dysphoria as they are ethnic altering (facial bone reduction), cosmetic rejuvenating (hairline advancement, brow life, neck liposuction) or contraindicated (zygoma fat grafting with prominent malar eminences): 15824 rhytidectomy forehead (reduction/hairline advancement), 21209 facial bone reduction, 15773 fat graft to zygoma, 67900 brow lift and 15876 liposuction neck.