Breast Augmentation denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgical breast augmentation for treatment of her gender dysphoria. The physician reviewer found that the patient presents with gender dysphoria which is a source of significant adverse effect on her mental health. She has been transitioning from the male-to-female gender over the past four to five years. She has been treated with hormonal therapy without adequate breast development. The patient is well-documented to have gender dysphoria. Currently, her examination and photographs depict a lack of breast development and is more consistent with male anatomy. The surgical concept of breast augmentation in male-to-female transgender patients is well-established and documented within the community of plastic surgeons.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for breast augmentation.For many transgender female patients, hormones alone do not adequately change breast appearance to address gender dysphoria. One study noted that “Although transwomen typically initiate hormonal therapy before surgical evaluation, there is a wide response range to estrogen therapy. Ultimately, the majority of individuals choose to pursue surgical intervention, with breast augmentation rates reported up to 67% in the transwomen population.” The authors noted further that “studies support breast augmentation as a quality-of-life operation and not simply a cosmetic procedure.” Similarly, The World Professional Association for Transgender Health, Inc.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A transgender enrollee has requested authorization and coverage for breast augmentation for treatment of the enrollee’s gender dysphoria. Findings: The physician reviewer found that The documentation provided does not support the medical necessity for the requested services in this clinical setting. The medical necessity of breast augmentation for transgender females with gender dysphoria is a case specific determination. This patient has documented gender dysphoria and has been undergoing female transitioning with hormonal therapy for approximately four years. Based on her diagnosis and history, her external anatomy should be more consistent with the female gender. However, her examination detail and review of the photographs support that she has had sufficient breast development with hormone therapy.

Nature of Statutory Criteria/Case Summary:An enrollee has requested breast augmentation for treatment of the enrollee’s gender dysphoria. The submitted documentation does not support the medical necessity for the requested services in this clinical setting. The patient has been assessed with gender dysphoria. The medical necessity of breast augmentation for transgender females with gender dysphoria is a case specific determination. The surgical concept of breast augmentation in individuals transitioning from the male-to-female gender is well-established and documented within the community of plastic surgeons. However, in this patient’s case, her examination and photographs depict breast development more consistent with a female than a male. The patient has been treated with hormone therapy and the submitted photographs document the presence of visible breast tissue.

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