Criteria
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:
- Postage stamp test
- Snap-Gauge Device
- RigiScan
- NPT testing using the RigiScan may be considered medically necessary only:
- When NPT testing is indicated; and
- The results of postage stamp or 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
- Dorsal nerve conduction latencies
- Evoked potential measurements
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); or
- Collagenase clostridium histolyticum injection (e.g., Peyronie’s disease).
Penile Prostheses and External Devices
Treatment of male sexual dysfunction with an internal penile prosthesisor 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 is considered not medically necessary for any other indication.
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 for any indication not listed above is considered not medically necessary.
Procedure Codes
| 36245 | 36246 | 36247 | 36248 | 37788 | 37790 | 51792 |
| 54115 | 54205 | 54230 | 54231 | 54250 | 54400 | 54401 |
| 54405 | 54406 | 54408 | 54410 | 54411 | 54415 | 54416 |
| 54417 | 74445 | 75736 | 84410 | 93975 | 93976 | 93978 |
| 93979 | 93980 | 93981 | 95870 | A4649 | J0270 | J0275 |
| J2440 | J2760 | L7900 | L7902 |