Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial feminization surgeries. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria. Gender dysphoria refers to distress that is caused by a discrepancy between a persons gender identity and that persons sex assigned at birth. This often results in depression and anxiety. Treatment for gender dysphoria aims to minimize dysphoria and help patients attain their sought-after gender role. A paper by Kalra notes that facial feminization procedures are not cosmetic, but rather serve a primarily reconstructive purpose in transgender women whose overall physical appearance otherwise prevents them from being perceived as female. The statement from Lamda aggregates opinions from multiple organizations including the American Medical Association, American Association of Family Physicians, Endocrine Society, American Psychiatric Association, American Psychological Association, American College of Obstetricians and Gynecologists, and the American Public Health Association. The authors note that the medical procedures attendant to sex reassignment are not cosmetic or elective or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. A publication by Gijs and Brewaeys notes that gender reassignment is the only treatment for gender dysphoria that has shown significant benefits in numerous research trials and meta-analyses over the past half century. A study by Ainsworth and colleagues concludes that Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. FFS [facial feminization surgery], GRS [gender reassignment surgery] or both) are associated with improved mental health-related quality of life  Further a paper by Altman notes that this surgery does not aim to rejuvenate the face but rather it helps transgender women in passing as a female and integrating into everyday society. In conclusion, the submitted documentation demonstrates the patient experiences significant anxiety and distress secondary to her male facial features. There is sufficient scientific literature demonstrating that facial feminization surgery is effective in relieving gender dysphoria in patients such as this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are 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 with expertise in treatment of gender dysphoria 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.