Facial Feminization Surgery and The Standards of Care

The Harry Benjamin International Gender Dysphoria Association and the Standards ofCare that it publishes are often resented by members of the transgender communityas an impediment to obtaining the services of physicians and surgeons (i.e. the“gatekeeper” role). HBIGDA could do much to alleviate this resentment by acting toadvocate for the “medical necessity” of the surgical procedures sought by members ofthe community.It is the writer’s contention that fulfilling the eligibility and readiness requirements(defined in the Standards of Care) and undergoing the associated psychological andpsychiatrist reviews (accompanied by the required documentation) constitute a defacto demonstration of “medical necessity”. The Standards of Care are currentlybeing used by everyone involved in the process as a substitute for a clear statementof “medical necessity” on the part of any individual. If this situation is not clarifiedthen any insurance company can reject requests for surgical intervention withoutcause. Now that transgender surgeries are no longer being excluded on the basisthat they are “cosmetic” in nature they may continue to be excluded because there isno way to demonstrate “medical necessity”. All an insurance company needs to do toreject a claim (for clearly covered procedures) is to have one of their Peer ClinicalReviewers state that the procedure is “not medically necessary”. Since there iscurrently no way to demonstrate “medical necessity” for any of the surgical proceduresthat constitute transgender medicine the insurance companies can choose to pay attheir own discretion. Following the guidelines defined in the Standards of Care todetermine “medical necessity” is the only possible way that this dilemma can berectified. A clear statement of this fact should be included in the next revision of theStandards of Care.My own approach to FFS eligibility and readinessIn my own case, I have approached this surgery with the same degree of carenormally given only to GRS (see excerpt from the Standards of Care, Version 6 1 ). I haveobtained written evaluations from my primary psychotherapist (Casey Weitzman)concerning the appropriateness of FFS in my case. I have also obtained a writtenevaluation of my case from a psychiatrist (Thomas A. Cotsen) acting in the evaluativerole required for a second GRS documentation letter but specifically addressing mydesire for FFS. Both Weitzman and Cotsen are extremely experienced gendertherapists who prepare similar documentation for GRS surgical recommendations(Appendix C). I have also obtained surgical evaluations from Dr. Douglas Ousterhout(San Francisco), Dr. Zukowski (Chicago), Dr. Chettawut (Thailand), and Dr. Suporn(Thailand) all of whom are recognized authorities in the field of facial feminizationsurgery (Appendix D). While I am not recommending that such documentation berequired for all patients seeking FFS it seemed highly advisable in my case. Theabsence of a defined procedure for FFS authorization in the Standards of Care mightlead my insurance company to assume that such surgery is not an intimate andessential part of my transition. I have not yet made a formal written request for facialfeminization surgery to Blue Cross of California. Coverage of FFS under the currentcontract language is clearly possible and guidance and commentary from HBIGDA iscritical before making such a formal request. I hope that by approaching FFS usingexactly the same authorization procedures reserved for GRS will lend credence to myposition.- 16 -