Diagnosis: Gender Dysphoria
Treatment: Facial feminization surgery
The insurer denied coverage for facial feminization surgery (rhinoplasty, face lift, and genioplasty)
The denial is overturned

The patient is a transgender female with a history of gender dysphoria and depression. The physician is requesting facial feminization surgery, rhinoplasty, face lift, and genioplasty to treat this patient's gender dysphoria.

According to the World Professional Association for Transgender Health (WPATH) guidelines, surgeries for assisting in body feminization include reduction thyroid chondroplasty, voice modification surgery, suction-assisted lipoplasty of the waist, rhinoplasty, facial bone reduction, face-lift, and blepharoplasty. Other surgeries for assisting in body masculinization include liposuction, lipofilling, and pectoral implants.

Although most of these procedures are generally labeled purely aesthetic, these same operations in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a given patient's life situation. This ambiguity reflects reality in clinical situations, and allows for individual decisions as to the need and desirability of these procedures. In this case, this patient has anxiety that this patient's mental health providers attribute directly to facial gender incongruity. The patient has significant dysphoria that the patient's physician believes is secondary to the incongruence of the patient's facial appearance with this patient's assigned sex. A study by Ainsworth and Spiegel (2010) found improved mental health functioning for transgender women following facial feminization surgery. In this case, this patient's condition represents a unique clinical situation for which facial feminization is considered medically indicated. A systematic literature review on facial feminization by Morrison et al. (2016) concluded that "based on these studies, it appears that facial feminization surgery is highly efficacious and beneficial to patients."

The requested procedures are necessary to treat this patient's unique clinical situation of disabling gender dysphoria and posttraumatic stress disorder (PTSD) related to the incongruence of this patient's facial appearance.

The health plan did not act reasonably with sound medical judgment, and in in the best interest of the patient.

The insurer's denial of coverage for Facial Feminization Surgery, Rhinoplasty, Face Lift, and Genioplasty (Procedure Codes 15824, 21120, 21139, 30410) is substantiated. The insurer's denial should be overturned.