BlueCross BlueShield of Tennessee Medical Policy Manual

Fractional Laser Treatment of Vulvovaginal Atrophy

DESCRIPTION

Vulvovaginal atrophy (VVA) also known as vaginal atrophy, atrophic vaginitis, and/or urogenital atrophy, is a condition that causes the vagina and tissue near the vagina to get dry, thin and inflamed. Vaginal atrophy is often caused by lack of a woman’s ability to produce estrogen due to any of the following:

Fractional carbon dioxide (CO2) lasers (e.g. MonaLisa Touch®, CO2RE Intima) are lasers traditionally used to treat skin wrinkles or acne scaring and have been proposed as a non-surgical treatment for vulvovaginal atrophy. This micro-ablative procedure can be done in the office, usually as a series of procedures and does not require anesthesia. The safety and effectiveness of these procedures has not been documented.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Fractional carbon dioxide (CO2) laser may require three treatments over an 18 week period and may require annual maintenance treatment. Due to multiple limitations of the few, small, short term studies this technology remains investigational.

SOURCES

American College of Obstetricians and Gynecologists (2007, reaffirmed in 2017) Committee opinion (#378) vaginal ‘rejuvenation’ and cosmetic vaginal procedures. Retrieved September 18, 2017 from: https://www.acog.org.

American Congress of Obstetricians and Gynecologists (2015, May) Position Statement: Fractional laser treatment of vulvovaginal atrophy and U.S. food and drug administration clearance. Retrieved August 26, 2016 from: https://www.acog.org.  

Arroyo, C. (2017, August). Fractional CO2 laser treatment for vulvovaginal atrophy symptoms and vaginal rejuvenation in perimenopausal women. International Journal of Women’s Health, (9), 591-595. (Level 4 evidence)

First Coast Services Option, Inc. (2016, July) Local Coverage Determination (LCD) Non-covered Services (L33777) Retrieved August 26, 2016 from: https://www.cms.gov.

Perino, A., Calligaro, A., Forlani, F., Tiberio, C., Cucinella, G., Svelato, A., et. al. (2014, December) Vulvo-vaginal atrophy: a new treatment modality using thermo-ablative fractional CO2 laser. Maturitas. 2014.12.006. Abstract retrieved August 26, 2016 from PubMed database.

Salvatore. S., Nappi, R., Zerbinati, N., Calligaro, A., Ferrero, S., Origoni. M., et.al. (2014, August)  A 12-week treatment with fractional CO2 laser for vulvovaginal atrophy: a pilot study.Climacteric;17(4):363-9.Abstract retrieved August 26, 2016 from PubMed database.

Society of Obstetricians and Gynaecologists of Canada. (2013, December)Female genital cosmetic surgery. Retrieved August 26, 2016 from the National Guideline Clearinghouse4. (NGC:010201)

Sokol, E. and Karram, M. (2016, July) An assessment of the safety and efficacy of a fractional CO2 laser system for the treatment of vulvovaginal atrophy. Menopause. 2016 Jul 11. Abstract retrieved August 26, 2016 from PubMed database.

U.S. Food and Drug Administration. (2011, January). Center for Devices and Radiologic Health. 510(k) Premarket Notification Database K103288. Retrieved August 26, 2016 from: http://www.fda.gov.

U.S. Food and Drug Administration. (2013, December). Center for Devices and Radiologic Health. 510(k) Premarket Notification Database K133895. Retrieved August 26, 2016 from: http://www.fda.gov.

ORIGINAL EFFECTIVE DATE:  1/14/2017

MOST RECENT REVIEW DATE:  11/9/2017

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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