1
OHCA Guideline
Medical Procedure Class:
Vulvectomy/Labiaplasty
Initial Implementation Date:
12/1/2014
Last Review Date:
3/5/2021
Effective Date:
4/1/2021
Next Review/Revision Date:
April 2024
* This document is not a contract, and these guidelines do not reflect or represent every conceived
situation. Although all items contained in these guidelines may be met, this does not reflect, or imply,
any responsibility of this agency or department to change the plan provision to include the stated
service as an eligible benefit.
New Criteria Revision of Existing Criteria
Summary
Purpose:
To provide guidelines to assure medical necessity and consistency in the prior
authorization process.
Description
Labiaplasty: Surgical alteration of the labia minora or majora. Typically reduction of the labia minora
is performed. This is the most common female genital cosmetic surgery (FGCS) performed.
Vulvectomy:
o A simple complete vulvectomy includes removal of all of the labia majora, labia minora, and
clitoris.
o A simple partial vulvectomy may include removal of part or all of the labia majora and labia
minora on one side and the clitoris.
o A partial radical vulvectomy includes partial or complete removal of a large, deep segment of
skin from the following structures: abdomen and groin, labia majora, labia minora, clitoris, mons
veneris and terminal portions of the urethra, vagina and other vulvar organs.
Definitions
Reconstructive Surgery
Reconstructive surgery is performed on abnormal structures of the body caused by congenital defects,
developmental abnormalities, trauma, accidental injury, infection, tumors or disease. It is generally
performed to improve function but may also be done to approximate a normal appearance.
Cosmetic Surgery
Cosmetic surgery is performed to reshape normal structures of the body to improve the patient's
appearance and self-esteem.
Note - Any expense incurred for cosmetic surgery for adults is not a benefit.
CPT Codes Requiring Prior Authorization (PA)
56620, 56625, and 56630 (See CPT manual for code descriptions)
Approval Criteria
INDICATIONS FOR PROCEDURES:
A. LABIAPLASTY
1. Labiaplasty for hypertrophic labia minora and/or labia majora is generally considered
cosmetic in nature and performed to improve appearance. For member age 16-20 years,
2
procedure may be considered for coverage if the member has a DSM classified diagnosis
certifying the procedure is emotionally necessary. (Procedures requested for girls under the
age of 16 are discouraged as labia continue to grow and reshape into adolescence.) All
requests should be referred to an OHCA Medical Director/Physician Consultant for review.
2. Labiaplasty may be considered medically indicated when documentation supports the
member has enlarged labia causing dyspareunia (i.e., painful intercourse or pain associated
with tampon insertion) that has not responded to conservative treatment.
B. VULVECTOMY
1. Vulvectomy may be considered medically indicated when documentation supports ONE of
the following:
A) Benign, pre-malignant, or malignant vulvar lesion(s); OR
B) Vulvar area with persistent infection, refractory to medical management; OR
C) In conjunction with medically indicated treatment of a congenital anomaly, including
fused labia and/or imperforate hymen; OR
D) In conjunction with medically indicated reconstructive surgery as a result of accidental
injury or trauma.
Note: Requests for any indications not listed above should be referred to an OHCA Director/Physician
Consultant for review.
References
1. Oklahoma Health Care Authority; Policies & Rules, OAC 317:30-3-1; 317:30-3-59; 317:30-5-60;
317:30-5-8
2. Novitas Solutions, Local Coverage Determination (L35090) Cosmetic and Reconstructive
Surgery, 11/7/2019.
3. BCBS Tennessee, medical guideline – Vulvectomy, 7/23/2020.
4. C. William Helm, MD, MBBChir, FRCS, MRCOG; UptoDate, Radical Vulvectomy, June 13,
2019 https://www.uptodate.com/contents/radical-vulvectomy?csi=4b82fa0e-e534-402f-9ded-
39c9777d27ac&source=contentShare
5. C. William Helm, MD, MBBChir, FRCS, MRCOG; UptoDate, Vulvar Wide Local Excision,
Simple Vulvectomy, and Skinning Vulvectomy, August 4, 2020,
https://www.uptodate.com/contents/vulvar-wide-local-excision-simple-vulvectomy-and-skinning-
vulvectomy?csi=c088736c-c47d-49d4-9b6e-f20e34263eb5&source=contentShare
6. Marc R. Laufer, MD, Jhansi Reddy, MD, FACOG; UptoDate, Labia Minor Hypertrophy,
November 30, 2020 https://www.uptodate.com/contents/labia-minora-
hypertrophy?csi=e43094ba-da7a-4fb9-805b-92b5bc87ad44&source=contentShare
