Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Labiaplasty
Policy #:MA11.067d

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.


Labiaplasty is not covered by the Company because cosmetic services are not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

However, when labiaplasty is performed as part of male to female intersex surgery for gender dysphoria and criteria are met, labiaplasty is considered medically necessary, and is, therefore, eligible for reimbursement.

Services performed due to recent trauma and/or accident may be eligible for coverage when performed within a year of the event or within a year of the time at which the member’s healing and/or skeletal and somatic maturation reasonably allows for repair and is intended to restore a member to a pre-trauma and/or pre-accident state, except when not covered by Medicare.
Policy Guidelines

There is no Medicare coverage determination addressing labiaplasty; therefore, the Company policy is applicable.

BENEFIT APPLICATION

Services that are cosmetic are excluded for the Company's Medicare Advantage products because they are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

Description

Labia minora hypertrophy (enlargement) is generally described as protuberant labial tissue that extends beyond the labia majora. Labial hypertrophy (enlargement of the labia minora or labia majora) may be congenital or caused by excessive androgenic hormones, and may be unilateral or bilateral. There is a wide range of “normal” female internal and external genitalia. Age is also a factor in the assessment of the female genitalia. For instance, the labia minora continue to develop in childhood and adolescence. Any asymmetry may correct itself during pubertal development. There is no standard diagnostic criteria for labial hypertrophy. The approach to management of labial hypertrophy should include counseling regarding personal hygiene and avoidance of tight fitting clothing and instruction on the variations of the normal female genitalia.

Labiaplasty, also called labia reduction surgery, involves the surgical removal of a portion of the labia minora or labia majora. Labiaplasty is generally cosmetic in nature and performed to improve appearance. Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function.

A vulvectomy is the removal of the tissue of the vulva and sometimes includes removal of the lymph nodes and tissue in the groin areas. The vulva includes the labia minora, labia majora, clitoris, and vaginal opening. Vulvectomy, in contrast to labiaplasty, is performed for oncologic indications, such as microinvasion carcinoma of the vulva or Paget's disease, or for severe lesions of the vulva not amenable to local excision.
References

Evidence of Coverage.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

THE FOLLOWING CODE IS USED TO REPRESENT LABIAPLASTY: 58999


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N90.60 Unspecified hypertrophy of vulva

N90.61 Childhood asymmetric labium majus enlargement

N90.69 Other specified hypertrophy of vulva



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

BILLING REQUIREMENTS

Labiaplasty must be reported using the Current Procedural Terminology (CPT) code 58999. Providers must not bill other procedure codes to represent labiaplasty (e.g., CPT codes: 15839, 56620, 56625, or 56630). These services are subject to post-payment review and audit procedures.





Policy History

Revisions for MA11.067d
06/05/2019This policy has been reissued in accordance with the Company's annual review process.
05/14/2018 The intent of this policy remains unchanged.

Revisions for MA11.067c
04/07/2017This version of the policy will become effective 04/07/2017.

The following criteria have been added to this policy:

When labiaplasty is performed as part of male to female intersex surgery for gender dysphoria and criteria are met, labiaplasty is considered medically necessary, and is, therefore, eligible for reimbursement.

Revisions for MA11.067b
10/01/2016This policy has been identified for the ICD-10 code update, effective 10/01/2016.

The following ICD-10 code has been Deleted N90.6 from the policy; the following ICD-10 code have been added to this policy: N90.60, N90.61, N90.69

Revisions for MA11.067a
02/15/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on labiaplasty
06/17/2015Revised policy number MA11.067a was issued as a result of annual policy review. This policy was updated to delineate the Company's coverage criteria for Labiaplasty.

MA11.067a
01/01/2015This is a new policy.




Version Effective Date: 05/14/2018
Version Issued Date: 05/14/2018
Version Reissued Date: 06/06/2019