Adolescent Minor Chest Surgery Appeal Letter Example
I am writing regarding your initial determination to deny Mr. Peter Patient's chest reduction procedure. I am Mr. Patient's primary care physician, and he has been in my care since August of 2017. Additionally, I am a board-certified Pediatrician and specialize in the care of transgender adolescents. I have no doubt that in Mr. Patient's case, medical necessity can be demonstrated for this procedure as required by New York Medicaid's regulations regarding Transgender Related Care and Services¹.
Mr. Patient experiences severe gender dysphoria related to the secondary sex characteristics of his natal sex, including his chest. He has had hormone treatment appropriate to his individual goals, including testosterone injections starting 10/1/2017. He has lived for well more than twelve months in a role congruent with his gender identity, living as a transgender man starting in September of 2015. There are no significant mental or physical health conditions that would contraindicate this gender affirming surgery, and he has the capacity to give informed assent to treatment. Two qualified mental health clinicians, Social Worker, LCSW and Psychiatrist, MD have concurred with my assessment in this regard. His legal guardian has also participated fully in his treatment plan, giving her informed consent as well.
The World Professional Association of Transgender Health includes specific guidance in the most recent Standards of Care (SOC) discussing chest masculinization for FtM (female to male transgender) patients before the age of 18. The adolescent section on Irreversible Interventions of the SOC addresses this: “Genital surgery should not be carried out until patients reach the legal age of majority in a given country (…) Chest surgery in FtM patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment.²” The SOC continues to discuss the negative impact of withholding treatments for adolescents in the section, Risks of Withholding Medical Treatments for Adolescents: “Refusing timely medical interventions for adolescents might prolong gender dysphoria and contribute to an appearance that could provoke abuse and stigmatization.” Medical literature subsequent to the publishing of the most recent standards of care continues to support chest reduction surgery in adolescent minors³,⁴, in addition to consensus statements from additional professional organizations⁵,⁶.
Recommendation
As discussed above, Mr. Patient meets all standards set forward in the SOC to be recommended as a candidate for this procedure. Given his diagnosis of persistent gender dysphoria (gender identity disorder ICD-9 302.85, ICD-10 F64.0), I have been collaborating with the mental health providers who have submitted additional recommendations, as well as Dr. Surgeon to whom Mr. Patient was referred, to provide appropriate treatment for the management of his documented symptoms of gender dysphoria. He has responded well to this treatment so far. The persistent gender dysphoria which originates from having developed Tanner 5 breasts negatively affects Mr. Patient's health and well-being, and this is not expected to change with the patient's age or time receiving masculinizing hormone therapy. The only treatment for this is a bilateral reduction mammoplasty with chest reconstruction.
It is my professional opinion that a chest reduction surgery is the next step in his treatment plan, that this will greatly improve his wellbeing, and that this treatment is medically necessary to treat his gender dysphoria. Please contact me if there is further documentation needed to demonstrate medical necessity for Mr. Patient’s procedure. We will assist Mr. Patient in accessing this treatment, including by referring him to legal services that will support him in overturning an unlawful denial that contradicts expert medical opinion and regulatory guidance.
Thank you,
Pediatrician, MD
1. 18 N.Y.C.R.R. § 505.2(l)(3) https://docs.dos.ny.gov/info/register/2016/dec7/pdf/rulemaking.pdf
2. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., … Zucker, K. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism, 13(4), 165–232. https://doi.org/10.1080/15532739.2011.700873
3. Olson-Kennedy, J., Warus, J., Okonta, V., Belzer, M., & Clark, L. F. (2018). Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults. JAMA Pediatrics, 172(5), 431. https://doi.org/10.1001/jamapediatrics.2017.5440
4. Schechter, L. (2018). 3.4 Gender Confirming Surgical Care in Adolescence: Evidence, Timing, Options, and Outcomes. Journal of the American Academy of Child & Adolescent Psychiatry, 57(10), S123–S124. https://doi.org/10.1016/j.jaac.2018.07.568
5. Rafferty, J. (2018). Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics, 142(4), e20182162. https://doi.org/10.1542/peds.2018-2162
6. Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., … T’Sjoen, G. G. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 102(11), 3869–3903. https://doi.org/10.1210/jc.2017-01658