HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
G-9-018
Topic:
Diagnosis and Treatment of Male Sexual Dysfunction
Section:
Miscellaneous
Effective Date:
September 9, 2019
Issued Date:
September 9, 2019
Last Revision Date:
August 2019
Annual Review:
August 2019
 
 

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 Position

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; or
      • 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 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 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 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.

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Related Policies

Refer to Medical Policy I-107, Injectable Collagenase Clostridium Histolyticum, for additional information.


Professional Statements and Societal Positions Guidelines

American Academy of Family Physicians (AAFP): 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): 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 patient. The AUA also recommends against penile venous surgery and considers ESWT investigational (AUA, 2018).

National Comprehensive Cancer Network (NCCN): According to NCCN guidelines for prostate cancer, recovery of erectile function is directly related to factors such as age at radical prostatectomy, preoperative erectile function and the degree of preservation of the cavernous nerves. Replacement of resected nerves with nerve grafts has not been shown to be beneficial (NCCN, 2019).


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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



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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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

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, and subject to the applicable laws of your state.


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.

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. 





Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect 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.