Transgender denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested an orchiectomy for treatment of her gender dysphoria. Findings: The physician reviewer found that based on the medical records provided for this review, the patient has well-documented gender dysphoria. She has undergone the recommended evaluation and consideration for gender transition. Her transition is supported by multiple therapists and physicians. She has been living socially as a female and has undergone hormonal therapy for an extensive period of time. According to the publication by Schechter, “Prior to performing gender reassignment surgery, the surgeon must be satisfied that the diagnosis of gender dysphoria has been established.” This patient meets this criterion.

Standard Review The parent of a transgender male enrollee has requested authorization and coverage for bilateral mastectomy with bilateral nipple areolar reconstruction (CPT codes 19350.50 and 19303.50). The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature for treatment of the enrollee’s gender dysphoria. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested facial feminization treatment of the enrollee’s gender dysphoria. Based on the entirety of the medical documentation provided for this review, the requested services are not medically necessary and are not reconstructive in nature. The medical literature supports facial feminization surgery which can include forehead remodeling, rhinoplasty, thyroid chondroplasty, and voice alteration procedures for treatment of gender dysphoria. However, the submitted documentation does not support a functional deficit in this patient’s case, for each of the requested services. The photographs show evidence of mild brow ptosis bilaterally, but no evidence of significant brow or lower forehead prominence, mild prominent ears, signs of facial aging of the lower face and neck.

Nature of Statutory Criteria/Case Summary:An enrollee has requested facial feminization surgeries for treatment of the enrollee’s gender dysphoria. Based on the entirety of the medical documentation provided for this review, the requested services are not medically necessary and are not reconstructive in nature. The medical literature supports facial feminization surgery which can include forehead remodeling, rhinoplasty, thyroid chondroplasty, and voice alteration procedures for treatment of gender dysphoria. However, the submitted documentation does not support a typical functional deficit in this patient’s case for each of the requested services. With respect to the patient’s forehead, hairline and brow treatment, there was insufficient documentation to justify these procedures. A formal examination was not documented.

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 transgender, then check the rights and deadlines that apply to your plan.