Highmark Commercial Medical Policy - Pennsylvania

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Medical Policy: G-9-017
Topic: Diagnosis and Treatment of Male Sexual Dysfunction
Section: Miscellaneous
Effective Date: May 7, 2018
Issue Date: May 7, 2018
Last Reviewed: April 2018

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.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Treatment of male sexual dysfunction with an internal or external penile prosthesis may be considered medical necessity when EITHER of the following is met:

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

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

  • Comprehensive history and physical examination
  • Lab tests for hormone levels of testosterone
    • Abnormal hormone levels may indicate further endocrine testing for pituitary, thyroid, and adrenal dysfunction.

Nocturnal penile tumescence (NPT) testing using the postage stamp test or the snap gauge test is rarely medically necessary. NPT may be considered medically necessary where clinical evaluation, including history and physical examination, is unable to distinguish psychogenic from organic impotence and any identified medical factors have been corrected. NPT testing using the RigiScan may be considered medically necessary only where 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, and therefore are not covered, because spinal cord injury and other neurological deficits that may cause erectile dysfunction are typically identified during a comprehensive history and examination. These tests do not have any therapeutic implications and are, therefore, not medically necessary:

  • Corpora cavernosal electromyography;
  • Dorsal nerve conduction latencies;
  • Evoked potential measurements.

The surgical implantation of an internal penile prosthesis may be considered medically necessary when the above criteria have been met and consideration has been given to a vacuum constriction device.

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 medically necessary removal of an internal penile prosthesis, when benefit coverage is available for the internal penile prosthetic device, the surgical re-implantation of a medically necessary internal penile prosthetic device may be covered.

Penile revascularization, artery, with or without vein graft 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.

An external or internal penile prosthesis is considered not medically necessary for any other indication.

Venous ligation performed as a treatment for erectile dysfunction 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, J0270, J0275, J2440, J2760

The following may be considered medically necessary:

  • Hormone injections (e.g., testosterone); or
  • The Snap-Gauge device; or
  • Vacuum constriction devices (e.g., ErecAid)
Procedure Codes
A4649, L7900, L7902

Place of Service: Inpatient/Outpatient

Diagnosis and Treatment of Male Sexual Dysfunction is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.


Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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