Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Labiaplasty

Policy #:11.06.09d

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

Labiaplasty is not covered by the Company because it is considered a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are 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 a specific benefit contract exclusion exists.

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.
Guidelines

BENEFIT APPLICATION

Services that are cosmetic are a benefit contract exclusion for all products of the Company. 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


Company Benefit Contracts.





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


Cross References


Policy History

Revisions from 11.06.09d:
05/14/2018This version of the policy will become effective 05/14/2018. The intent of this policy remains unchanged.


Effective 10/05/2017 this policy has been updated to the new policy template format.
Version Effective Date: 05/14/2018
Version Issued Date: 05/14/2018
Version Reissued Date: N/A

Connect with Us        


2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.