Facial Laser Hair Removal denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial laser hair removal. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s gender dysphoria and are not reconstructive in nature. Findings: The requested services are medically necessary for treatment of the patient’s medical condition in this clinical setting. Facial laser hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. The patient was born with genetics to grow terminal hair on the face. Excessive facial hair in a female would be considered abnormal and is referred to as hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in female in areas that are normally found in males.

Nature of Statutory Criteria/Case Summary: A 29-year-old enrollee has requested facial laser hair removal. Findings: The physician reviewer found that the patient has a history of gender dysphoria and has been treated with cross-gender hormone therapy since 2010. The patient reported that the facial hair limits their ability to be perceived as female and negates their gender identity. The patient’s symptoms of gender dysphoria are reportedly exacerbated when they were mis-gendered due to the presence of facial hair. The patient’s mental health evaluation documents exacerbation of gender dysphoria symptoms due to the presence of facial hair. Guidelines for the medical necessity of facial feminization surgery (FFS) exist in two reviews from World Professional Association for Transgender Health (WPATH) and the Transgender Law Center.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has a medical history of gender dysphoria. A letter from the patient’s representative dated 12/7/18 states that the patient has been taking cross gender hormone therapy since July 2018. The letter reported that the patient’s symptoms of gender dysphoria have manifested with persistent anxiety, depression, agoraphobia, and overall distress. She has met with her medical provider to discuss laser facial hair removal, and the provider determined that facial laser hair removal is appropriate to treat her gender dysphoria. The letter states that the patient’s facial hair severely limits her ability to be perceived as female and thus negates her gender identity. Being constantly mis-gendered due to the presence of facial hair exacerbates her symptoms of gender dysphoria.

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 Laser Hair Removal, then check the rights and deadlines that apply to your plan.