Labiaplasty - Medical Necessity Criteria
Criteria for documenting medical necessity of labiaplasty
Contents:
- Does health insurance cover labiaplasty?
- What are possible medical reasons for labiaplasty?
- Medical necessity criteria for labiaplasty
- Frequently asked questions
- Documentation to submit
- Health plan criteria for labiaplasty and other references
Does health insurance cover labiaplasty?
Labiaplasty and other procedures on the external genitalia are generally considered cosmetic and not medically necessary when they are done for the purpose of improving appearance, enhancing sexual performance, or improving self-esteem. In this context, they will not be covered by health insurance. However, it is possible for labiaplasty to be covered when it is judged to be medically necessary for a patient’s condition.
What are possible medical reasons for labiaplasty?
Medical conditions for which labiaplasty may be performed include congenital asymmetrical labial growth causing functional impairment, recurrent rashes, non-healing ulcers, and dyspareunia.
Medical necessity criteria for labiaplasty
When is labiaplasty medically necessary?
Labiaplasty may be considered medically necessary in adults who are documented to meet one or more of the following criteria:
- Atypical genitalia
- Childhood asymmetry labium majus enlargement (CALME, or congenital asymmetrical labial growth) that causes functional impairment
- Congenital labial defect (for example, as a result of congenital adrenal hyperplasia)
- Dyspareunia
- Interference in basic activities and/or functions
- Recurrent rashes or non-healing ulcers in the affected area, despite appropriate conservative topical treatment
Labiaplasty may also be considered medically necessary when it is done in the context of medically necessary intersex surgery / gender confirming surgery.
Labiaplasty — including labia minora reduction and labia major reshaping — is considered NOT medically necessary when done for cosmetic purposes, that is, for the purpose of improving appearance, enhancing sexual performance, or improving self-esteem.
Frequently asked questions
How much does labiaplasty cost?
Depending on the extent of the procedure and where you have it done, labiaplasty can cost anywhere from $2,000 to $8,000.
How long does it take for a labiaplasty to heal?
Recovery time is different from person to person. Some patients can return to work and other normal activities in as little as 2 days, though it may take up to 2 weeks. Most swelling is gone within 2 to 6 weeks, and swelling will usually be completely gone in 4 to 6 months.
Documentation to submit
These are the things you can prepare documentation of in order to support your statement that labiaplasty is medically necessary. Submit only those that apply.
Documentation of conditions for which labiaplasty may be considered medically necessary:
Health plan criteria for labiaplasty and other references
- Aetna Criteria for Cosmetic Surgery
- Anthem Blue Cross Criteria for Cosmetic and Reconstructive Services of the Trunk and Groin
- Blue Cross Blue Shield of Michigan Medical Policy on Cosmetic and Reconstructive Surgery
- Cigna Medical Coverage Policy on Redundant Skin Surgery
- Geisinger Health Plan Medical Benefit Policy on Management of Excessive Skin and Subcutaneous Tissue
- Health Net of California Criteria for Cosmetic and Reconstructive Surgery
- HealthPartners Criteria for Cosmetic Surgery / Treatments
- LifeWise Health Plan of Washington Medical Policy on Cosmetic and Reconstructive Services
- Premera Blue Cross Criteria for Cosmetic and Reconstructive Services
- Tufts Health Plan Medical Necessity Guidelines on Reconstructive and Cosmetic Surgery