Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A transgender enrollee has requested authorization and coverage for facial feminization surgeries CPT code 21121 (reconstruction of chin); CPT code 21137 (reduction forehead); CPT code 21209 (reduction of facial bones); and CPT code 67911 (repair brow defect) for treatment of the enrollees gender dysphoria and are not reconstructive in nature. Findings:  The physician reviewer found that based on the entirety of the medical 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. Thus, facial feminization surgery can help to approximate a feminine appearance. The request for the reduction of her forehead, CPT code 21137, is medically necessary but the other requested services are not. The examination documented by the provider supports a masculine appearance of this patients forehead and anterior hairline. However, the brow position as well as the chin and mandibular contour could be considered normal for a female appearance. The photographs show evidence of a gender neutral chin, mandibular contour and brow position. Overall, the clinical documentation is insufficient to support the requested services except for the forehead. Thus, the patients facial appearance is consistent in the spectrum of the female gender except for her forehead and anterior hairline. As such, a portion of the requested services is medically necessary for treatment of this patients gender dysphoria.  Specifically, CPT code 21137 (reduction forehead) is medically necessary for the treatment of this patients gender dysphoria. However, facial feminization surgeries CPT code 21121 (reconstruction of chin); CPT code 21209 (reduction of facial bones); and CPT code 67911 (repair brow defect) are not medically necessary.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 forehead and anterior hairline constitute an abnormal body structure for a female gender. CPT code 21137 (reduction forehead) would be reconstructive in nature. Additionally, the requested CPT code 21137 (reduction forehead) would provide a more than a minimal improvement to the extent possible. In this patients case, the requested CPT code 21137 (reduction forehead) would approximate a more normal female appearance of her forehead based on her history of gender dysphoria. However, the patients facial presentation as to CPT code 21121 (reconstruction of chin); CPT code 21209 (reduction of facial bones); and CPT code 67911 (repair brow defect) are not reconstructive in nature. As noted and reasoned above, the requested facial feminization surgeries as to CPT code 21121 (reconstruction of chin); CPT code 21209 (reduction of facial bones); and CPT code 67911 (repair brow defect) are more consistent with aesthetic improvement and are not specific to gender related abnormalities. In sum, the requested CPT code 21137 (reduction forehead) is reconstructive in nature. However, CPT code 21121 (reconstruction of chin); CPT code 21209 (reduction of facial bones); and CPT code 67911 (repair brow defect) are not 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 a portion of the requested services is reconstructive in nature. Therefore, the Health Plans denial should be partially overturned. 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.