Diagnosis and Treatment of Male Sexual Dysfunction

Policy ID: G-9-024

Section: Miscellaneous

Effective Date: November 01, 2019

Revised Date: May 30, 2025

Revision Effective Date: September 01, 2025

Last Reviewed: May 13, 2025

Applies To: Commercial and Medicaid Expansion

Description

Erectile dysfunction is defined as the inability to achieve a sufficient erection for satisfactory sexual performance. Erectile function requires competent arterial blood inflow as well as a reduction of venous blood outflow. Disease and other risk factors may affect the arterial and venous systems in a manner that impedes erectile function and may lead to erectile dysfunction.

Oral and topical pharmacological treatments are not addressed in this policy.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; and/or

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Diagnosis of Male Sexual Dysfunction

The following procedures and tests for the diagnosis of erectile dysfunction may be considered medically necessary:

Comprehensive history and physical examination
Lab tests for testosterone levels
- Abnormal testosterone levels may necessitate further endocrine testing for hypothalamus, pituitary, thyroid, and adrenal dysfunction.
Nocturnal Penile Tumescence (NPT) testing
- NPT testing may be considered medically necessary when the following criteria are met:
  - Clinical evaluation, including history and physical examination, is unable to distinguish psychogenic from organic erectile dysfunction; and
  - Any identified medical disorders have been corrected.
- Types of NPT testing that may be considered medically necessary:
  - Snap-Gauge Device; or
  - RigiScan
    - NPT testing using the RigiScan may be considered medically necessary only:
      - When NPT testing is indicated; and
      - The results of Snap-Gauge testing are equivocal or inconclusive.
- All other indications for NPT are considered not medically necessary.

The following diagnostic procedures are considered not medically necessary, as these tests do not have any therapeutic value because spinal cord injury and other neurological deficits that may cause erectile dysfunction are typically identified during a comprehensive history and examination:

Corpora cavernosal electromyography; and
Dorsal nerve conduction latencies; and
Evoked potential measurements

Procedures and testing for erectile dysfunction not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

51792

54230

54231

54250

74445

84410

95870

Treatment of Male Sexual Dysfunction

The following treatments may be considered medically necessary for male sexual dysfunction:

Vacuum constriction devices (e.g., ErecAid); or
Vasodilator injection (e.g., papaverine, phentolamine, alprostadil); or
Vasodilator suppository (e.g., alprostadil).

Treatment of male sexual dysfunction not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

54205

E0201

J0270

J0275

J2440

J2760

L7900

L7902

Penile contracture devices

Penile contracture devices (e.g., RestoreX) are considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Code

E0201

Penile Prostheses

Surgical implantation of an internal penile prosthesis may be considered medically necessary when EITHER of the following criteria is met:

Erectile dysfunction is due to an organic disease or injury and is not psychological in nature; or
Treatment failure, contraindication, or intolerance to pharmacological therapy is present.

The surgical implantation of an internal penile prosthesis may be considered medically necessary when the above criteria have been met.

The removal of an internal penile prosthesis may be considered medically necessary for ONE or more of the following indications:

Infection; or
Mechanical failure; or
Urinary obstruction; or
Intractable pain.

Following the removal of an internal penile prosthesis it may be considered medically necessary for surgical re-implantation of an internal penile prosthetic device.

An internal penile prosthesis insertion or removal not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

54115

54400

54401

54405

54406

54408

54410

54411

54415

54416

54417

Penile Revascularization

Penile revascularization may be considered medically necessary for the treatment of erectile dysfunction when ALL of the following criteria are met:

The individual presents with erectile dysfunction preceded by blunt perineal or pelvic trauma; and
The individual has erectile dysfunction that is secondary to a focal arterial occlusion, as evidenced by an arteriogram or duplex ultrasonography conclusive for focal arterial obstruction; and
There is no evidence of generalized vascular disease (e.g., diabetes mellitus, hypertension, coronary artery disease), Peyronie's plaques, intracavernosal masses, nodules, or sensory neuropathy; and
There is evidence of normal corporeal venous function; and
Alternative nonsurgical treatment modalities have been fully explained to the individual, and the individual is determined to achieve spontaneous erections without the need for pharmacological, external, or internal support devices; and
The individual is not actively smoking.

Venous ligation performed as a treatment for erectile dysfunction is considered not medically necessary.

Penile revascularization not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

36245

36246

36247

36248

37788

37790

75736

93975

93976

93978

93979

93980

93981

Diagnosis Codes

Covered diagnosis codes for procedure codes: 54115, 54205, 54230, 54231, 54250, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, and 74445

N48.6

N52.01

N52.02

N52.03

N52.1

N52.2

N52.31

N52.32

N52.33

N52.34

N52.35

N52.36

N52.37

N52.39

N52.8

N52.9

T83.21XA

T83.22XA

T83.23XA

T83.24XA

T83.24XD

T83.24XS

T83.25XA

T83.25XD

T83.25XS

T83.29XA

T83.29XD

T83.29XS

T83.410A

T83.410D

T83.410S

T83.411A

T83.411D

T83.411S

T83.418A

T83.418D

T83.418S

T83.420A

T83.420D

T83.420S

T83.421A

T83.421D

T83.421S

T83.428A

T83.428D

T83.428S

T83.490A

T83.490D

T83.490S

T83.491A

T83.491D

T83.491S

T83.498A

T83.498D

T83.498S

T83.61XA

T83.61XD

T83.61XS

T83.62XA

T83.62XD

T83.62XS

T83.69XA

T83.69XD

T83.69XS

T83.81XA

T83.81XD

T83.81XS

T83.82XA

T83.82XD

T83.82XS

T83.83XA

T83.83XD

T83.83XS

T83.84XA

T83.84XD

T83.84XS

T83.85XA

T83.85XD

T83.85XS

T83.86XA

T83.86XD

T83.86XS

T83.89XA

T83.89XD

T83.89XS

T83.9XXA

T83.9XXD

T83.9XXS

Professional Statements and Societal Positions Guidelines

American Academy of Family Physicians (AAFP) - 2016

According to the AAFP, oral phosphodiesterase-5 inhibitors are the first-line treatments for ED. Second-line treatments include alprostadil, vacuum devices and when all other options are ineffective surgically implanted penile prostheses are an option (Rew et al., 2016).

American Urological Association (AUA) - 2018

In 2018, the AUA published revised guidelines on erectile dysfunction. According to the guidelines, men may choose to begin with the least invasive option, however any type of treatment as an initial treatment is a valid choice. The clinician is responsible to ensure that the man and his partner fully understand the benefits and risks/burdens associated with the choice and be informed of all the treatments (e.g., vacuum erection device, penile prosthesis) that are not contraindicated for the individual. The AUA also recommends against penile venous surgery and considers ESWT investigational.

ND Committee Review

Internal Medical Policy Committee 9-26-2019 This policy was originally brought to the July IMPC prior to the new changes

Internal Medical Policy Committee 1-19-2021 Annual Review

Internal Medical Policy Committee 9-21-2021 Revision of policy

Removed procedure code A4649; and
Distributed procedure codes throughout policy; and
Addition of two (2) statements

Internal Medical Policy Committee 9-28-2022 Revision of policy

Updated criteria

Internal Medical Policy Committee 5-23-2023 Annual Review - no change in criteria

Internal Medical Policy Committee 3-19-2024 Coding update - Effective April 01, 2024

Added new procedure code S4988; and
Added Policy Application.

Internal Medical Policy Committee 3-11-2025 Annual Review -no changes in criteria

*Special Note: With the arrival of April 2025 New codes from CMS post March IMPC. Procedure code(s) E0201 has been added and S4988 has been removed to March's IMPC with the effective date of April 01, 2025.

Internal Medical Policy Committee 5-13-2025 Revision with coding - Effective September 01, 2025

Added new section 'Penile contracture devices;' and
Added procedure code E0201.

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: G-9-022

Section: Miscellaneous

Effective Date: November 01, 2019

Revised Date: March 09, 2025

Revision Effective Date: May 05, 2025

Last Reviewed: March 11, 2025

Archived Date: August 31, 2025

Applies To: Commercial and Medicaid Expansion

Description

Oral and topical pharmacological treatments are not addressed in this policy.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Diagnosis of Male Sexual Dysfunction

The following procedures and tests for the diagnosis of erectile dysfunction may be considered medically necessary:

Comprehensive history and physical examination
Lab tests for testosterone levels
- Abnormal testosterone levels may necessitate further endocrine testing for hypothalamus, pituitary, thyroid, and adrenal dysfunction.
Nocturnal Penile Tumescence (NPT) testing
- NPT testing may be considered medically necessary when the following criteria are met:
  - Clinical evaluation, including history and physical examination, is unable to distinguish psychogenic from organic erectile dysfunction; and
  - Any identified medical disorders have been corrected.
- Types of NPT testing that may be considered medically necessary:
  - Snap-Gauge Device; or
  - RigiScan
    - NPT testing using the RigiScan may be considered medically necessary only:
      - When NPT testing is indicated; and
      - The results of Snap-Gauge testing are equivocal or inconclusive.
- All other indications for NPT are considered not medically necessary.

Corpora cavernosal electromyography; and
Dorsal nerve conduction latencies; and
Evoked potential measurements

Procedures and testing for erectile dysfunction not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

51792

54230

54231

54250

74445

84410

95870

Treatment of Male Sexual Dysfunction

The following treatments may be considered medically necessary for male sexual dysfunction:

Vacuum constriction devices (e.g., ErecAid); or
Vasodilator injection (e.g., papaverine, phentolamine, alprostadil); or
Vasodilator suppository (e.g., alprostadil).

Treatment of male sexual dysfunction not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

54205

E0201

J0270

J0275

J2440

J2760

L7900

L7902

Penile Prostheses and External Devices

Treatment of male sexual dysfunction with an internal penile prosthesis or an external device may be considered medically necessary when EITHER of the following criteria is met:

Erectile dysfunction is due to an organic disease or injury and is not psychological in nature; or
There is failure, a contraindication, or an intolerance to pharmacological therapy.

The surgical implantation of an internal penile prosthesis may be considered medically necessary when the above criteria have been met.

The removal of an internal penile prosthesis may be considered medically necessary for ANY ONE of the following indications:

Infection; or
Mechanical failure; or
Urinary obstruction; or
Intractable pain.

Following the removal of an internal penile prosthesis it may be considered medically necessary for surgical re-implantation of an internal penile prosthetic device.

An external device or an internal penile prosthesis insertion or removal not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

54115

54400

54401

54405

54406

54408

54410

54411

54415

54416

54417

Penile Revascularization

Penile revascularization may be considered medically necessary for the treatment of erectile dysfunction when ALL of the following criteria are met:

The individual presents with erectile dysfunction preceded by blunt perineal or pelvic trauma; and
The individual has erectile dysfunction that is secondary to a focal arterial occlusion, as evidenced by an arteriogram or duplex ultrasonography conclusive for focal arterial obstruction; and
There is no evidence of generalized vascular disease (e.g., diabetes mellitus, hypertension, coronary artery disease), Peyronie's plaques, intracavernosal masses, nodules, or sensory neuropathy; and
There is evidence of normal corporeal venous function; and
Alternative nonsurgical treatment modalities have been fully explained to the individual, and the individual is determined to achieve spontaneous erections without the need for pharmacological, external, or internal support devices; and
The individual is not actively smoking.

Venous ligation performed as a treatment for erectile dysfunction is considered not medically necessary.

Penile revascularization not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

36245

36246

36247

36248

37788

37790

75736

93975

93976

93978

93979

93980

93981

Diagnosis Codes

Covered diagnosis codes for procedure codes: 54115, 54205, 54230, 54231, 54250, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, and 74445

N48.6

N52.01

N52.02

N52.03

N52.1

N52.2

N52.31

N52.32

N52.33

N52.34

N52.35

N52.36

N52.37

N52.39

N52.8

N52.9

T83.21XA

T83.22XA

T83.23XA

T83.24XA

T83.24XD

T83.24XS

T83.25XA

T83.25XD

T83.25XS

T83.29XA

T83.29XD

T83.29XS

T83.410A

T83.410D

T83.410S

T83.411A

T83.411D

T83.411S

T83.418A

T83.418D

T83.418S

T83.420A

T83.420D

T83.420S

T83.421A

T83.421D

T83.421S

T83.428A

T83.428D

T83.428S

T83.490A

T83.490D

T83.490S

T83.491A

T83.491D

T83.491S

T83.498A

T83.498D

T83.498S

T83.61XA

T83.61XD

T83.61XS

T83.62XA

T83.62XD

T83.62XS

T83.69XA

T83.69XD

T83.69XS

T83.81XA

T83.81XD

T83.81XS

T83.82XA

T83.82XD

T83.82XS

T83.83XA

T83.83XD

T83.83XS

T83.84XA

T83.84XD

T83.84XS

T83.85XA

T83.85XD

T83.85XS

T83.86XA

T83.86XD

T83.86XS

T83.89XA

T83.89XD

T83.89XS

T83.9XXA

T83.9XXD

T83.9XXS

Professional Statements and Societal Positions Guidelines

American Academy of Family Physicians (AAFP) - 2016

American Urological Association (AUA) - 2018

ND Committee Review

Internal Medical Policy Committee 9-26-2019 This policy was originally brought to the July IMPC prior to the new changes

Internal Medical Policy Committee 1-19-2021 Annual Review

Internal Medical Policy Committee 9-21-2021 Revision of policy

Removed procedure code A4649; and
Distributed procedure codes throughout policy; and
Addition of two (2) statements

Internal Medical Policy Committee 9-28-2022 Revision of policy

Updated criteria

Internal Medical Policy Committee 5-23-2023 Annual Review - no change in criteria

Internal Medical Policy Committee 3-19-2024 Coding update - Effective April 01, 2024

Added new procedure code S4988; and
Added Policy Application.

Internal Medical Policy Committee 3-11-2025 Annual Review -no changes in criteria

*Special Note: With the arrival of April 2025 New codes from CMS post March IMPC. Procedure code(s) E0201 has been added and S4988 has

been removed to March's IMPC with the effective date of April 01, 2025.

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