Diagnosis:Gender Dysphoria
Treatment:Surgical services

Diagnosis: Gender Dysphoria/ Female to male
Treatment: Surgical services/ Mastectomy
The health plan denied the procedure as not medically necessary. The health plan determination is upheld.

This is a female to male transgender patient. Breast surgery was performed 10 years ago but the patient has pain and discomfort in the chest due to the redundant skin and breast tissue in both axillae. Dermatitis and intertrigo have required treatment with over-the-counter (OTC) and prescription medications. Repeat top surgery is planned.

The requested health service of Mastectomy, simple, complete, and full thickness graft is not medically necessary for this patient.
The patient has already had top surgery. He is reported to have excess skin that is causing intertrigo and rashes, but the records do not include photos that show rashes or include treatment notes from his primary care physician documenting treatment for the rashes from the redundant breast tissue. The patient is reported to have dermatitis and intertrigo. The medical records do not provide any documentation in the form of PCP or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. In addition, photos showing chafing are not provided for review. Supporting PCP or dermatology note documentation should be provided to confirm the history provided by the patient to the plastic surgeon.
The procedure will improve the appearance of the patient's chest wall. The patient has already had top surgery, and revision is not medically necessary in the absence of photos and PCP or dermatology note documentation of treatment for rashes.
The WPATH guidelines support trans-gender top surgery. In this case, the patient has already had top surgery but is not happy with the outcome of the surgery. Photos showing the patient's chest are not provided, and therefore it is not possible to independently verify that that the patient's result is outside the range of expected outcomes following top surgery.