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A Qualitative Analysis of Independent Medical Reviews in California for Gender Affirming Procedure Denials
George Durisek, Jorge Garcia-Flores, Emily Pfahl, Annie Chen, Dr. Anna Schoenbrunner
The Ohio State University College of Medicine
2024-01-15
Presenter: George Duisek
Affidavit:
This is the original work of The Ohio State University College of Medicine and Department of Plastic and Reconstructive Surgery, comprised of the authors listed in the abstract. Geroge was part of the group and contributed a significant and appropriate portion of the work.
Director Name: Dr. Cristiane Ueno
Author Category: Medical Student
Presentation Category: Clinical
Abstract Category: General Reconstruction
Background:
Addressing gender dysphoria requires consideration of diverse individual factors, surpassing a simplistic approach. Our study delves into insurance denial claims for gender-affirming procedures in California, specifically those subjected to Independent Medical Review (IMR). We analyzed both upheld and overturned cases, categorizing decisions based on the reviewer's rationale, specialty, and the utilization of national guidelines and peer-reviewed literature.
Methodology:
We conducted a qualitative review of 230 publicly available records provided by California's Department of Managed Health Care Independent Medical Review on insurance denials for gender-affirming procedures between 2016 and 2023. Variables collected included claim year, treatment subcategory, patient demographics, reviewer specialty, and citation of national guidelines and peer-reviewed evidence. Overturned decisions were categorized as medically necessary, reconstructive, case-by-case, or other. Upheld decisions were broken down into insufficient medical necessity documentation, gender-neutral appearance, aesthetic vs. reconstructive, prerequisites not met, misalignment with medical literature, and other.
Results:
Findings expose inconsistencies in applying national guidelines and peer-reviewed literature when reviewing claims, with claims only citing at rates of 64% and 45%, respectively. Overturned claims predominantly hinge on being medically necessary (60%), while upheld claims are often attributed to insufficient documentation (26%), gender-neutral appearance (22%), and ambiguity in aesthetic versus reconstructive intent (22%).
Discussion and Conclusion:
Our research underscores the distinctive nature of gender-affirming care, advocating for a withdrawal from generic denial approaches and a shift to case-specific care. To create a more inclusive healthcare system, the study emphasizes the crucial need for transparency and consistency in decision-making for gender-affirming care claims.
