Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has enrollee has requested authorization and coverage for removal of vulva, simple partial for treatment of the enrollees hypertrophy of the vulva and other specified conditions associated with female genital organs and is not reconstructive in nature. Findings:  The physician reviewer found that There is a lack of support for the requested procedure in this clinical setting. Clinical labia minora hypertrophy remains a poorly defined diagnosis. Labia minora hypertrophy is generally described as protuberant labial tissue that projects beyond the labia majora. However, there is no consensus among gynecologists, pediatricians, or plastic surgeons regarding the use of objective clinical measurements to confirm the diagnosis.  To examine the labia minora to evaluate for hypertrophy, the standard procedure is to gently extend the labia to their full width in the medial-lateral axis. The measurement of this width is the stretch width. In the early practice, labia minora has been classified as hypertrophic when the maximal width between the midline and the lateral free edge of the labia minora (when the labia were extended laterally by the examiner) measures greater than 5 cm. In current practice, a stretch width of greater than 6 cm is generally felt to be consistent with hypertrophy. The initial approach to management is patient counseling and self care instruction. If symptoms persist after extensive counseling and instruction in vulvar care, then surgical correction may be offered. However, with surgical correction, scarring, chronic vulvar pain and dyspareunia may result. In this case, the patient was described as having normal external genitalia on initial examination.  Subsequently, her labia minora was described as being slightly larger on the right, and extending 1 cm beyond her labia majora. According to the standard classification of labia minora hypertrophy, her condition would be considered a normal anatomic variant and should not be the cause of her symptoms. The patient does not meet the criteria for the requested procedure. Based on the medical evidence, surgery would not be the appropriate treatment for this patient and could actually cause additional problems. There are a number of treatment options that could help resolve her symptoms and many of them are non-surgical. Therefore, removal vulva simple, partial surgery has not been demonstrated as medically necessary for treatment of this patients medical condition.With regards to whether the requested procedure is reconstructive in nature, based on the documentation provided, the patients genitalia has a relatively normal appearance and does not constitute an abnormal structure of the body.  Upon examination, the provider noted, normal external genitalia and her labia minora was described as being slightly larger on the right, and extending 1 cm. The examination notes support findings that are consistent with a normal anatomic variant As such, surgery to reduce the minimal asymmetry would be cosmetic in nature.  For these reasons, removal vulva simple, partial  surgery is not reconstructive in nature.Final Result: The reviewer determined that requested procedure is not medically necessary for treatment of the patients medical condition and is not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.