Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial feminization surgeries: CPT 67900  50 repair of brow ptosis; 31599  unlisted procedure; larynx; CPT 30420  rhinoplasty, primary; including major; CPT 14060  adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; CPT 61782  stereotactic computer-assisted (navigational) procedure; cranial, extradural; CPT 15733  muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle; CPT 15769  grafting of autologous soft tissue, other, harvested by direct excision; CPT 15774  grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof; CPT 20902  bone graft, any donor area; major or large; and CPT 21175  reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts). The purpose of medically necessary facial feminization surgery is to relieve gender dysphoria, which the surgery does through harmonization with regard to other modified structures...achieving an aesthetic result beyond gender difference.. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that, for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATHs SOC further states that although facial feminization procedures are labeled purely aesthetic, these procedures in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. This patient has a history of gender dysphoria. She has socially transitioned, successfully and consistently living in a gender role congruent with her affirmed gender identity since 2018. The records provided for review report that the requested facial feminization surgeries will help the patients appearance to be more closely aligned with her gender identity. Given these findings, the requested facial feminization surgeries: CPT 67900  50 repair of brow ptosis; 31599  unlisted procedure; larynx; CPT 30420  rhinoplasty, primary; including major; CPT 14060  adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; CPT 61782  stereotactic computer-assisted (navigational) procedure; cranial, extradural; CPT 15733  muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle; CPT 15769  grafting of autologous soft tissue, other, harvested by direct excision; CPT 15774  grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof; CPT 20902  bone graft, any donor area; major or large; and CPT 21175  reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) are medically necessary for 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 with expertise in transgender health 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.