Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender dysphoria.
Treatment: Facial feminization surgery.

The insurer denied coverage for facial feminization surgery.  The denial is modified. 

This patient is a transgender female (male-to-female) with a history of gender dysphoria.  The patient has been referred for facial feminization surgery (FFS) to address her gender dysphoria.

The following services are requested:  1) 15824: Brow Lift, 2) 21172: Reconstruction superior-lateral orbital rim and lower forehead, 3) 30410: Rhinoplasty, 4) 30520: Septoplasty, and 5) 31899: Trachea Shave.

Forehead reconstruction (21172) and trachea shave (31899) are medically necessary.  According to the World Professional Association for Transgender Health (WPATH) guidelines, pages 63-64: "Other surgeries for assisting in body feminization include reduction thyroid chondroplasty (reduction of the Adam's apple), voice modification surgery, suction-assisted lipoplasty (contour modeling) of the waist, rhinoplasty (nose correction), facial bone reduction, face-lift, and blepharoplasty (rejuvenation of the eyelid).  Other surgeries for assisting in body masculinization include liposuction, lipofilling, and pectoral implants.  Voice surgery to obtain a deeper voice is rare but may be recommended in some cases, such as when hormone therapy has been ineffective.
Although these surgeries do not require referral by mental health professionals, such professionals can play an important role in assisting clients in making a fully informed decision about the timing and implications of such procedures in the context of the social transition...".

This patient has anxiety that her mental health providers attribute directly to her facial gender incongruity.  She has significant dysphoria that her physicians believe is secondary to the incongruence of her facial appearance with her assigned sex.  

A study by Ainsworth et al. found improved mental health functioning for transgender women following facial feminization surgery.  Her condition represents a unique clinical situation in which facial feminization is indicated.  A systematic literature review on facial feminization by Morrison et al. concluded: "based on these studies, it appears that facial feminization surgery is highly efficacious and beneficial to patients."  Forehead reconstruction and trachea shave are necessary to treat the patient's unique clinical situation of disabling dysphoria related to the incongruence of her facial appearance.  Prominent forehead and brows and prominent Adam's apple are uniquely male, and codes 21172 and 31899 will address the facial incongruity.

Rhinoplasty and septoplasty are not medically necessary.  Both male and female noses have many different shapes, and individual assessment is necessary to confirm that the patient has a "male" nose.  In this case, photos are not provided to confirm that her nasal appearance is outside the range of possibility for a feminine nose.  Septoplasty is not medically necessary because the records do not document nasal obstruction due to septal deviation that has not responded to medical therapy.  The septum is intra-nasal and thus is unlikely to be a source of gender incongruity.

Brow lift is not medically necessary.  This patient is unlikely to have significant brow rhytids or drooping brow.  Forehead reduction will change the projection of the forehead.  It is unclear why brow lift would make this patient more feminine in appearance. Photos are not provided to show a brow appearance that is significant discordant with the patient's female gender. The health plan acted reasonably in part.

The insurer's denial of coverage for facial feminization procedures (codes 15824, 21172, 30410, 30520, 31899 and 30520) is modified. Forehead reconstruction (21172) and trachea shave (31899) are medically necessary. The rest of the requested procedures are denied as not medically necessary.