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Erectile Dysfunction (ED)
What is it?
# 01056
CPTS and HCPCS Codes –
C1813, C2622, J0270, J0275, J2440, J2760, L7900,
S0090, 37788, 54400 – 54417
Experimental Codes –
J1070, J1080, J3120, J3130, J3140, J3150. 51792,
54240, 54250, 83550, 84066, 95900 – 95904, 95925,
95927
Erectile dysfunction (ED) (such as impotence) is defined as the inability to achieve or
maintain an erection sufficient for satisfactory sexual performance. ED affects between 15
and 30 million American men. There are multiple causes of ED including disease processes,
psychological conditions, trauma, drug and alcohol use/abuse, as well as smoking. ED may
occur as a result of an underlying medical condition, such as diabetes, kidney disease,
hormonal imbalance, multiple sclerosis, atherosclerosis, vascular disease or neurological
disease. Injury to the penis, spinal cord, prostate, bladder, and pelvis may also cause ED.
Surgery, especially radical prostate or bladder surgery can injure the nerves and arteries
near the penis resulting in ED. Many medications have ED as a side effect and include:
antihypertensive drugs, antihistamines, antidepressants, tranquilizers, opiates, and appetite
suppressants. Psychological factors (such as stress, anxiety, depression, and low selfesteem) cause 10–20% of ED cases.
Note: The treatment of male sexual dysfunction, including ED, is specifically excluded under
some benefit plans; therefore, penile prostheses and other treatments may not be covered
or limited. When coverage is available it is subject to the terms, conditions and limitations of
the applicable benefit plan.
Criteria
Diagnosis of ED
There are a variety of diagnostic tests that are considered medically necessary in order to
diagnose ED including – serum testosterone, pharmacological response testing using
vasoactive drugs and thyroid function studies.
„ However, the following tests for diagnosis of ED are considered experimental and
investigational:
•
Dorsal nerve conduction latencies – 95900 - 95904
•
Evoked potential measurements – 95925 - 95927
•
Iron binding capacity - 83550
•
Nocturnal penile tumescence (NPT) or rigidity testing – 54250 - using postage stamp or
snap gauge test unless clinical evaluation including history and physical exam are
unable to distinguish psychogenic from organic impotence and any identified medical
factors have been corrected. RigiScan is considered medically necessary only when
postage stamp or snap gauge testing are inconclusive.
•
Penile plethysmography - 54240
•
Prostatic acid phosphatase - 84066
•
Stimulus evoked response (measurement of bulbocavernosus reflex latency time) 51792
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Treatment of ED
Once ED has been diagnosed and documented, treatment is considered medically
necessary only when the condition is the result of or related to an organic disease or injury
(not psychological in nature – Diagnoses Codes 302.70 – 302.79). Therapy should be
applied in a stepwise fashion with increasing invasiveness and risk balanced against the
likelihood of efficacy. Injectable and oral agents have become the first line treatment option
for ED. The following therapies for the treatment of ED are considered medically
necessary:
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Injectable Medications given into the corpus cavernosa or through a small
catheter into the urethra. The latter procedure is known as MUSE – Medicated
Urethral System for Erection. Medications include:
1) Papaverine – J2440;
2) Alprostadil (prostaglandin E1 or Caverject) – J0270, J0275; and,
3) Phentolamine – J2760.
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Oral Medications. However many benefit plans exclude coverage for drugs for
lifestyle enhancement or performance. Medications include:
1) Viagra® - sildenafil citrate (S0090);
2) Levitra® - vardenafil hydrochloride; and,
3) Cialis® - tadalafil.
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Testosterone replacement therapy (J1070, J1080, J3120, J3130,
J3140, J3150) including transdermal preparations are considered
experimental and investigational for the treatment of nonhypogonadal impotence because effectiveness has not been
established.
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Topical creams or gels containing vasodilators (such as Verapamil
cream) are experimental and investigational for treatment of ED
because their effectiveness has not been established.
External Devices or vacuum constriction devices (such as Osbon ErecAid™
and Rejoyn Vacuum Therapy System – L7900) are considered medically
necessary when prescribed by a physician as an alternative to medication
therapies for ED.
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external devices are considered experimental and
investigational for all other indications including for the prevention
of erectile dysfunction following prostatectomy.
Implantable Devices or semi-rigid (AMS Malleable 650 and Mentor Genesis™ C2622) or inflatable (AMS 700 CXM and Mentor Alpha 1® - C1813) implantable
penile prostheses (54400 – 54417) are considered medically necessary after
failure or contraindication to medical therapies.
Removal of internal penile prosthesis is considered medically necessary for
any of the following indications:
1) infection; or,
2) mechanical failure; or,
3) urinary obstruction; or,
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4) intractable pain.
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Implantable penile prostheses are considered experimental and
investigational for all other indications.
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As surgery destroys the corpus cavernosus of the penis, this
procedure precludes any future pharmacological treatment.
Surgical Penile Revascularization (37788) for vasculogenic ED is considered
medically necessary for members who meet all of the following criteria:
1) Member is less than 55 years old; and,
2) ED is direct result of an arterial injury caused by blunt trauma to the pelvis
and/or perineum (902.50, 902.54, 902.59); and,
3) Blockage of arterial inflow is demonstrated by duplex Doppler ultrasound or
arteriography (440.8 – 440.9, 607.82); and,
4) Diagnostic testing reveals normal corporeal venous function; and,
5) Member is not diabetic (250.00 – 250.93) and has no systemic vascular
occlusive disease; and,
6) Member does not actively smoke.
Notice
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Penile revascularization is considered experimental and
investigational for other indications.
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Arterial reconstructive procedures – dorsal vein arterialization
procedures or penile venous occlusive surgery (venous ligation or
dorsal vein ligation – 37790) in men with ED secondary to
arteriosclerotic occlusive disease is experimental and
investigational because it has not been proven to be effective.
Policies are designed to provide medical guidelines that are applicable for the majority of individuals with
a particular disease, illness, or condition. In addition, policies are designed to supplement the medical necessity
terms as defined in the member's Policy or Benefit Plan. Therefore,
policies alone can not override specific
Policy or Benefit plan language regarding coverage, limitations and exclusions. In the event of conflict, the Policy
or Benefit Plan shall govern. Any
policies included herein do not constitute medical advice or the practice of
policy to
medicine. Rather, they are intended only to establish general guidelines. Application of a
determine medical necessity in an individual instance is not intended, implied or construed to take priority over the
professional judgment of a treating provider. In all situations, the treating provider must use professional judgment
to provide the care believed to be in the best interest of the patient, and the provider and patient remain
responsible for all treatment decisions.
Sentinel retains the right to review and update
policies at its sole discretion.
Policies are proprietary
information of Sentinel. Any sale, copying or dissemination is prohibited; however, limited copying is permitted for
individual use.
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