Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool https://www.highmarkhealthoptions.com/providers/prior-auth-lookup

Procedures

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.

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

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

·       Dorsal nerve conduction latencies

·       Evoked potential measurements

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

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

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

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.

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.