Gender Dysphoria denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for scheduling of the requested phalloplasty surgical procedure. The records indicate that this patient has a history of gender dysphoria status post transition from female-to-male. The patient has been treated with hormones, bilateral mastectomies, and hysterectomy. The patient has requested treatment with phalloplasty. As noted in the medical literature, “Phalloplasty is a critical step for many transgender men who seek relief from gender dysphoria; however, phalloplasty is a difficult and complex surgery with many potential complications…mostly comprised of urethrocutaneous (UC) fistulas and urethral strictures.” With regard to urethral complications following gender-affirming phalloplasty, one study noted that the “Overall complication rate was high at 76.5%, of which urethral complication…

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for any or all of the following gender-affirming surgical procedures: harvesting of fat via liposuction from the upper-lower abdomen and flanks; fat grafting to the face; scapular spine shave; anterior costal cartilage shave; Opus Plasma and Morpheus8 skin treatments to the face and body; and lip lift.Harvesting of fat via liposuction from the upper-lower abdomen and flanks may be indicated as body contouring, but there is a lack of sufficient documentation of the dysphoria experienced by the patient to specifically necessitate these treatments.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving gender dysphoria, then check the rights and deadlines that apply to your plan.