Facial Feminization Surgery denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for any or all of the following requested facial feminization surgeries (21175 - reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (e.g., plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts); 21139 - reduction forehead, contouring and setback of anterior frontal sinus wall; 30420 - rhinoplasty, primary, including major septal repair; 20902 - bone graft, any donor area; major or large 61782 - stereotactic computer-assisted (navigational) procedure, cranial, extradural (list separately in addition to code for primary procedure); 21025 - excision of bone (e.g., for osteomyelitis or bone abscess), mandible; 21122 – genioplasty, sliding osteotomies, two or more osteotomies (e.g., wedge excision or…

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial feminization surgeries: CPT 67900 – 50 repair of brow ptosis; 31599 – unlisted procedure; larynx; CPT 30420 – rhinoplasty, primary; including major; CPT 14060 – adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; CPT 61782 – stereotactic computer-assisted (navigational) procedure; cranial, extradural; CPT 15733 – muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle; CPT 15769 – grafting of autologous soft tissue, other, harvested by direct excision; CPT 15774 – grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof; CPT 20902 – bone graft, any donor area; major or large; and CPT 21175 – reconst…

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: A transgender enrollee has requested authorization and coverage for facial feminization surgeries Findings: The physician reviewer found that based on the entirety of the medical documentation provided for this review including review of the photographs, the requested services are not medically necessary and are not reconstructive in nature. The patient is well documented to have gender dysphoria. Thus, facial feminization surgery and tracheal shave surgery can help to approximate a more feminine appearance. However, there should be sufficient documentation that the patient’s current features are abnormal for a female. This has not been adequately documented for this case. There was not a detailed examination documented by the plastic surgeon supporting abnormal features of the patient.

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 Facial Feminization Surgery, then check the rights and deadlines that apply to your plan.