Vulvectomy
DESCRIPTION
Vulvar cancer is a rare disease in which malignant cells form in the tissues of the vulva. Vulvar intraepithelial neoplasia (VIN) are pre-cancerous lesions in which abnormal cells are found in the surface layer (epithelium) of the vulvar skin. The grade of VIN is based on the depth of the abnormal cells into the epithelium. VIN 1 is low grade and usually goes away without treatment. VIN 2 and 3 are considered high-grade VIN and usually require treatment.
Appropriate treatment options, depending upon the size and extent of the primary lesion, include vulvectomy to remove either part or the entire vulva (the outer part of the female genitals). A partial vulvectomy (i.e. wide local excision) involves removal of a margin of healthy skin (usually 1 to 2 centimeters) around the primary lesion and a thin layer of fat below. A modified radical vulvectomy removes part of the vulva with or without nearby lymph nodes and is typically a treatment option for stages 2 and 3. A radical vulvectomy removes the entire vulva as well as nearby lymph nodes. Radical vulvectomy may be a treatment option for large stage 2 tumors, as well as stage 3 and 4 cancers.
POLICY
Vulvectomy is considered medically necessary for treatment of vulvar cancer.
Partial vulvectomy (i.e., wide local excision) is considered medically necessary for the treatment of vulvar intraepithelial neoplasia (VIN) 2 and 3.
Vulvectomy for the treatment of other conditions, including, but not limited to, discomfort, hypertrophy and/or for altering appearance is considered not medically necessary.
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the medical policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
SOURCES
American College of Obstetricians and Gynecologists. (2016, October; reaffirmed 2020). ACOG Committee Opinion. Number 675. Management of vulvar intraepithelial neoplasia. Retrieved July 5, 2023 from http://www.acog.org.
American College of Obstetricians and Gynecologists. (2016, September; reaffirmed 2020). ACOG Committee Opinion. Number 673. Persistent Vulvar Pain. Retrieved July 5, 2023 from http://www.acog.org.
National Comprehensive Cancer Network. (2022, December). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Vulvar cancer version 1.2023. Retrieved July 5, 2023 from the National Comprehensive Cancer Network.
ORIGINAL EFFECTIVE DATE: 10/11/2008
MOST RECENT REVIEW DATE: 11/30/2023
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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