
201906-118327
2019
Aetna
EPO
Gender Dysphoria
Surgical Services
Medical necessity
Upheld
Case Summary
Diagnosis: Male to female transgender
Treatment: Bilateral mammoplasty, augmentation with prosthetic implant 19325-50
The 19325-50 - bilateral mammoplasty, augmentation with prosthetic implant was not medically necessary.
Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person's gender identity and that person's sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). Treatment is available to assist people with such distress to explore their gender identity and find a gender role that is comfortable for them. Medical treatment options include, for example, feminization or masculinization of the body through hormone therapy and/or surgery.
Clinical documentation provided includes a letter from a LCSW and psychiatrist, a letter from the Legal Aid Society, and clinical notes from the treating surgeon including operative report. No clinical photographs are provided.
The documentation states the patient is a 38 B bra size in regards to breast size and wishes to be a "large C" or "small D." The operative report states the implants placed were 650 cubic centimeters (cc) in size. There is no mention of Tanner scale in regards to breast development. Based on this clinical information, there is inadequate clinical information regarding the lack of breast development necessitating breast augmentation since the patient is already a B cup. In addition, there are no photographs demonstrating incongruency of body appearance in associated with breast volume and shape that would require breast augmentation.
Based on the clinical information reviewed, there is inadequate documentation regarding evidence of clinically significant distress in social, occupational, or other areas of functioning. There are two letters of attestation which are brief and general in description. No actual clinical notes are present describing clinically significant functional issues secondary to distress that would necessitate breast augmentation.
Therefore, based on the clinical documentation provided, and the medical literature reviewed, adequate documentation of a presurgical medical necessity regarding breast augmentation has not been established. Therefore, medical necessity has not been established for augmentation mammoplasty. The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.