Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 14-year-old transgender male who was diagnosed with gender dysphoria. Findings:  The physician reviewer found that the record includes multiple evaluations from therapists and adolescent medicine specialists attesting to the patients severe chest dysphoria and pain caused by chest binding, as contributing to significant distress. Chest surgery was recommended by several experts in adolescent transgender care as a treatment for the patients gender dysphoria. In a letter dated 10/30/18, the provider noted the patient was first aware of his male gender identity at eight years old. The patient was unsure how to communicate his gender identity to his parents and peers, which resulted in depression, anxiety, and maladaptive coping and led to hospitalization. In a letter dated 5/21/19, the provider noted the patient began treatment with testosterone in October 2018, and he continues to have severe dysphoria related to his chest. The provider noted that the patient demonstrated an understanding of the risks and benefits of the requested procedures and was capable of making the decision to undergo surgery. The patients parent has requested coverage for double mastectomy (CPT 19303), nipple/areolar reconstruction (CPT 19350), and free graft with closure trunk (CPT 15200). The Health Plan denied the request and reported the requested procedures are not medically necessary for the treatment of this patient. At issue in this case is whether double mastectomy (CPT 19303), nipple/areolar reconstruction (CPT 19350), and free graft with closure trunk (CPT 15200) are medically necessary for the treatment of the patients medical condition. The requested procedures were denied by the patients Health Plan due to the patient being under 18 years of age. The World Professional Association for Transgender Health (WPATH) indicates that chest surgery in transgender male patients could be carried out earlier than 18 years of age, preferably after ample time of living in the desired gender role. Refusing timely medical interventions for adolescents might prolong gender dysphoria. Olson-Kennedy and colleagues report chest surgery in transgender male adolescents has been demonstrated to be a safe and effective treatment for gender dysphoria. Chest dysphoria was high among pre-surgical transmasculine youth, and surgical intervention positively affected both minors and young adults. In this case, the patient has been treated with testosterone since October 2018, and he continues to have severe gender dysphoria related to his chest. The requested procedures were recommended by multiple experts as medically necessary for the treatment of the patients gender dysphoria. The medical evidence supports the requested procedures in this clinical setting. Therefore, double mastectomy (CPT 19303), nipple/areolar reconstruction (CPT 19350), and free graft with closure trunk (CPT 15200) are medically necessary for the treatment of this patient. 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 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.