Vulvectomy
DESCRIPTION
Vulvectomy refers to a gynecological procedure in which the vulva is partially or completely removed; usually performed as a last resort in certain cases of cancer, vulvar dysplasia, or genital warts resulting from human papilloma virus (HPV).
POLICY
Vulvectomy procedure for the treatment of vulvar carcinoma and precancerous lesions is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Vulvectomy procedure for the treatment of other conditions/diseases, including, but not limited to, the following: hypertrophy and scarring is considered cosmetic.
See also: Human Papillomavirus (HPV) Vaccine
MEDICAL APPROPRIATENESS
Vulvectomy is considered medically appropriate if a biopsy documents ANY ONE of the following:
Cancerous tissue
Precancerous viral infestation
Resistant viral infestation
SOURCES
American Cancer Society. (2008, December). Cancer reference information. Detailed guide: Vulvar cancer surgery. Retrieved March 9, 2010 from http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Surgery_45.asp?sitearea.
BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2003). Reconstructive/cosmetic services (10.01.09). Retrieved March 9, 2010 from BlueWeb. (0 articles and/or guidelines reviewed)
de Hulla, J. A., Hollema, H., Lolkema, S., Boezen, M., Boonstra, H., Burger, M., et al. Surgery and radiotherapy in vulvar cancer. Critical Reviews in Oncology/Hematology, 60 (1), 38-58.
Duong, T. H., & Flowers, L. C. (2007). Vulvo-vaginal cancers: Risks, evaluation, prevention, and early detection. Obstetrics and Gynecology Clinics, 34 (4), 783-802.
Weikel, W., Schmidt, M., Steiner, E., Knapstein, P., & Koelbl, H. (2006). Surgical therapy of recurrent vulvar cancer. American Journal of Obstetrics and Gynecology, 195 (5), 1293-1302.
ORIGINAL EFFECTIVE DATE: 10/11/2008
MOST RECENT REVIEW DATE: 4/8/2010
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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