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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for labiaplasty (CPT 15839 and 56620). Findings:  The physician reviewer found that The most popular of the female genital cosmetic surgeries is labiaplasty, which involves cutting back the labia minora so that they sit flush with, or are entirely hidden by, the labia majoraThe labia minora can be short or long, smooth or wrinkled, light or dark, and one side may be longer or wider, which is similar to the asymmetry of many body partsAll studies found a wide disparity in labial length (range 5-100 mm) and labial width (range 1-60 mm). Sorice and colleagues stated that, Even among those who accept labiaplasty as a beneficial procedure, there is disagreement about the indicationsQualifying lengths vary by the classification used. This patient complains that her right labium is larger than her left. This is supported on physical examination. No measurements were submitted in the records and no photographs were received for review. The patient complains of constant pain and discomfort, and she complains of significant pain and discomfort performing activities of daily living including sitting. However, the patients complaints of pain and discomfort are not supported in the medical history and examinations received from her providers. Labial asymmetry is a normal variant. There is a lack of documentation that the patients labial asymmetry is not a normal variant. Moreover, the patients complaints of pain are not supported by any documentation received for review. Based on the medical information received for review, the requested labiaplasty (CPT 15839 and 56620) is not medically necessary for treatment of this patient. The California Reconstructive Surgery Statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Based on the medical information received for review, the condition does not constitute an abnormal structure of the body. The documentation received for review does not demonstrate that the patients labial asymmetry in not within normal limits. Therefore, the requested labiaplasty (CPT 15839 and 56620) is not reconstructive in nature for treatment of this patient. All told, the requested labiaplasty (CPT 15839 and 56620) is not medically necessary and not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery 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.