Sexual_dysfunction_treatment_male.fm

File Name:
Policy Number:
Origination:
Last Review:
Active policy, no longer scheduled for routine literature review.
Description of Procedure or Service
Sexual Dysfunction describes any of a group of sexual disorders characterized by inhibition either of sexual desire or the physiological changes that usually characterize sexual response. Sexual dysfunction disorders are generally classified into four categories: sexual desire disorders, sexual arousal disorders, orgasm disor-ders, and sexual pain disorders.
Male sexual dysfunction may reflect problems with the following factors: Libido, ejaculation, erectile func-tion or a combination of these factors. Erectile Dysfunction (ED), also known as impotence, is the inability to achieve and maintain penile erection and thus engage in sexual intercourse. This is a common, treatable condition affecting an estimated 18 million men in the United States alone. Yet, data suggest that less than 10% of affected men actually receive treatment. Male sexual dysfunction may be a result of one or more of the following conditions: medication side effects, endocrine disorders, peripheral disdysfunction, penile diseases, psychological disorders, and lifestyle factors. Once male sexual dys-function is diagnosed, each of these potential causes must be carefully addressed prior to initiating treatment.
Active policy, no longer scheduled for routine literature review.
BCBSNC will provide coverage for Treatment of Male Sexual Dysfunction when it is determined to be
medically necessary because the medical criteria and guidelines shown below are met.
Benefits Application
Please refer to Certificate for availability of benefits. This policy relates only to the services or supplies described herein. Benefits may vary according to benefit design, therefore certificate language should be reviewed before applying the terms of the policy.
When Treatment of Male Sexual Dysfunction is covered
When all of the following criteria are met:
The history and physical exam of the patient/member are consistent with sexual dysfunction; and
Policy: Sexual Dysfunction Treatment, Male
The patient has a medi) condition that directly contributes to sexual dysfunction; and
The treatment rendered is listed below as “services eligible for coverage." A. Causes and Treatment
Injury or disease means nerve, damage reasonably expected to result in impotence. This may be due to an accident, pelvic surgery, radiation therapy, or connective tissue es of erectile dysfunction include, but are not limited to the fol-lowing: Acquired: Peyronie’s Disease, penile fibrosis Congenital: Congenital curvature/chordee, micropenis Medications: antihypertensive (B-Blockers), antidepressants, tricyclics and monoamine oxi-dase inhibitors Arterial procedures: aorto-iliac-femoral bypass iii. Urologic procedures: Transurethral (TURP), radiand radical Policy: Sexual Dysfunction Treatment, Male
iii. ALS (Amyotrophic Lateral Sclerosis or Lou Gehrig’s disease) Services eligible for coverage for men with sexual dysfunction due tocauses include:
Treatment of the underlying /medical condition causing sexual dysfunction.
Oral prescription medications for erectile dysfunction such as Viagra®, Levitra® and Cialis®.
Most BCBSNC benefit plans have a limit of 4 tablets per 30 days. These medications have been
shown toeffects of nitrates and are contraindicated in patients taking any
form of nitrates or have known allergy to nitrates. Caution should also be taken in patients taking
alpha-blockers as the combination may produce hypotension. Safety and efficacy of use with other
treatments for erectile dysfunction have not been studied and are not recommended. Viagra®,
Levitra® and Cialis® are not indicated for use by newborns, children or women.
Penile injection therapy which involves the self-injection of medications into the base of the penis.
Papavarine, phenotolamine, and/or prostaglandin E1 (alprostadil) (Caverject®, Edex®) are com-
monly used. This type of therapy is most useful when causes and lesser for Most BCBSNC benefit plans have a limit of 4 units
per 30 days.
MUSE (Medicated Urethral System for Erection). This consists of a urethral suppository (alpros-tadil) in a very small, smooth plastic applicator. Once the applicator is in place, a button is pushed down which pushes the suppository out into the urethra where it is absorbed. Most BCBSNC ben-efit plans have a limit of 4 units per 30 days.
A vacuum erection system which is an external device used to provide erection in men and may be used in some cases as an alternative to the implanted device.
Surgical implantation of a Penile Prosthesis. Implantation of a penile prosthesis may be considered
medically necessary for men who meet all of the following criteria:
Results from Nocturnal Penile Tumescence (NPT) and/or rigidity testing (e.g., Rigi-scan) indi-
cate that the erectile dysfunction psychogenic in nature; and
Patient has attempted the above less invasive therapies (a, b, c, d, and/or e) with failure to have an adequate erection.
Surgical revascularization. Penile revascularization may be considered medically necessary only in
men less than 50 years old who meet all of the following criteria:
The erectile dysfunction is the direct result of an arterial injury caused by blunt trauma to the
pelvis and/or perineum; and
A focal blockage of arterial inflow is demonstrated by duplex Doppler ultrasonography or arte-
riography; and
iii. Diagnostic work-up reveals normal corporeal venous function; and
iv. Member is not diabetic and has no evidence of systemic lusive disease; and
When Treatment of Male Sexual Dysfunction is not covered
When the above medical criteria and guidelines are not met.
Viagra®, Levitra® and Cialis® are not indicated for newborns, children, or women.
Policy: Sexual Dysfunction Treatment, Male
Treatment of sexual dysfunction not related to disease is excluded under most plans.
Sural nerve graft in dered investigational.
Arterial reconstructive procedures, dorsal vein arterialization procedures, or penile venous occlusive surgery (e.g., venous ligation, dorsal vein ligation) in men with erectile dysfunction secondary to arte-riosclerotic occlusive disease are considered investigational.
Topical cream or gel containing vasodilators are considered investigational.
Extracorporeal shock wave therapy (ESWT) for Peyronie’s Disease is considered investigational.
Policy Guidelines
Most BCBSNC benefit plans have a limit of 4 units (tablets, suppositories, ampules, vial, kits, etc.) per 30 days. Providers are encouraged to limit refills to prevent waste or misuse. Prescriptions should only be for diagnoses of origin.
Billing/Coding/Physician Documentation Information
This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Poli-cies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.
Applicable Codes: 37788, 37790, 54200, 54205, 54230, 54231, 54235, 54250, 54360, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, J0270, J0275, J2760, J2440, L7900, S0090, Information necessary for review of medical necessity are: A letter of medical necessity and/or complete history and physical, and Diagnosis consistent with organic cause of sexual dysfunction as listed above. BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.
Policy Key Words
Key Words: Prosthesis, Penile, Vacuum Erection System, Alprostadil, MUSE, Papavarine, Viagra, Impo-tence, Impotency, Sexual Dysfunction, Treatment, SUR6645 Medical Term Definitions
Cystectomy
surgical removal of the bladder; surgical removal of a cyst.
Hypotensive
Policy: Sexual Dysfunction Treatment, Male
Iatrogenic
any adverse condition in a patient occurring as a result of treatment by a physician or surgeon, espe-cially to infections acquired by the patient during the course of treatment.
Neurogenic
arising from or caused by the nervous system.
Neurological
refers to a physiological cause; pertaining to or arising from an organ or the organs.
Potentiate
increasing of potency; particularly, the synergistic action of two drugs, being greater than the sum of the effects of each used alone.
Prostatectomy
surgical removal of the prostate gland.
Vascular
pertains to blood vessels in the body.
Scientific Background and Reference Sources
For policy entitled Sexual Dysfunction, Treatment
BCBSA Medical Policy Reference Manual - "Allied" Section, Page L5000 Stedman’s Medical Dictionary, 26th Ed. Williams & Wilkins, copyright 1995, p.859.
FDA approval of Alprostadil, MUSE, 11/19/96 FDA approved product insert on Viagra, 1998 Urology 1999, Sept; 54 (3): pp.385-391; "Female Sexual Dysfunction: Incidence, Pathophysiology, Evaluation, and Treatment Options" USPDI, Vol. 1, 19th Edition, 1999 pp. 2574-2577 Specialty Matched Consultant Advisory Panel - 5/2001 Specialty Matched Consultant Advisory Panel - 9/2001 BCBSA Medical Policy Reference Manual, 11/20/01; 2.01.46 and 7.01.81 For policy separated into Sexual Dysfunction Treatment, Male
BCBSA Medical Policy Reference Manual, 12/18/02; 2.01.25 Policy: Sexual Dysfunction Treatment, Male
American Association of Clinical Endocrinologists (AACE) Male Sexual Dysfunction Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of male sexual dysfunction: A couple's problem--2003 update. Endocr Pract. 2003;9(1):77-95.
BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.81, 4/29/03 U.S. Food and Drug Administration (FDA) website re: Viagra (http://www.fda.gov/cder/foi/label/1998/viagralabel2.pdf) accessed May 7, 2004 U.S. Food and Drug Administration (FDA) website re: Levitra (http://www.fda.gov/cder/foi/label/2003/021400lbl.pdf) accessed May 7, 2004 U.S. Food and Drug Administration (FDA) website re: Cialis (http://www.fda.gov/cder/foi/label/2003/021368lbl.pdf) accessed May 7, 2004 Specialty Matched Consultant Advisory Panel review 5/23/03 BCBSA Medical Policy Reference Manual, 10/9/03; 2.01.62 Specialty Matched Consultant Advisory Panel - 5/24/05 Policy Implementation/Update Information
For policy entitled Sexual Dysfunction, Treatment
Revised: Added statement regarding documentation of Rigi-scan when determining organic versus psychogenic impotence.
Revised: Added vacuum erection system and coding.
Revised: Alprostadil added to policy as result of FDA approval.
Revised: Renamed from Implantation of Penile Prosthesis to Treatment of Male Impotency. Added definition of impotence, Papavarine and Viagra. Defined information required to document medical necessity. Added examples of vascular diseases and neurologic diseases that may cause impotence Reformatted, Renamed from Treatment of Male Impotency to Sexual Dysfunction, Medical Term Definitions added.
12/99 Medical Policy Advisory Group.
Revised. Coverage criteria expanded to include more specific indications for women.
Specialty Matched Consultant Advisory Panel review (5/2001). Name changed to Sexual Dysfunc-tion Treatment from Sexual Dysfunction. Criteria reformatted for ease of understanding. 54200-54205, 54230, 54231, 54235, and 54250 added to applicable codes.
Specialty Matched Consultant Advisory Panel review. Changed statement in When Treatment of Sexual Dysfunction is Covered from "Age related decline in estrogen levels (e.g., menopause)" to "Age related decline in estrogen and/or testosterone levels (e.g., menopause)" Policy revised. Added statement under when it is not covered to include "vacuum therapy as a treatment of female sexual dysfunction is considered investigational" and "sural nerve graft in Policy: Sexual Dysfunction Treatment, Male
association with radical prostatectomy is considered investigational". Codes 54406-54417 and 64999 added to Billing/Coding Section and the System Application Guidelines.
Sexual Dysfunction Treatment policy separated, new policy name is Sexual Dysfunction Treatment,
5/27/04 Sexual Dysfunction Treatment policy separated. Name changed from Sexual Dysfunction Treat- ment to Sexual Dysfunction Treatment, Male. Removed references to female sexual dysfunction. Specialty Matched Consultant Advisory Panel review 5/23/03. Description, Benefits Application and Billing/Coding sections revised. Under "When covered" section A.1.a. - added v. Hyperthy-roidism & vi. Hypothyroidism; A.1.b. is now Anatomic/Structural causes: i. Acquired: Peyronie’s Disease, penile fibrosis & ii. Congenital: Congenital curvature/chordee, micropenis; A.1.c - removed alcohol as this is a lifestyle factor; A.1.d.iii - added Transurethral prostatectomy (TURP); A.1.e. - added iii. Penile trauma; A.1.f.ii - changed "Cardiac" to Cardiovascular Disease; A.1.f. added iv. Peripheral vascular disease; A.1.g. - added iv. Parkinson’s Disease; A.2.b. - added Levitra and Cialis, added most BCBSNC benefit plans have a limit of 4 tablets per 30 days, added infor-mation re: caution in patients taking alpha-blockers; A.2.c. - Provided more information re: Penile injection therapy, listed several other drugs & separated MUSE into A.2.d with description of pro-cedure; A.2.f. - added "Surgical" implantation of.; A.2.g - Added criteria for coverage of surgi-cal revascularization. Under "When not covered", second bullet, added Levitra and Cialis; added the following four bullets: Oral yohimbine therapy; Arterial reconstructive procedures, dorsal vein arterialization procedures, or penile venous occlusive surgery (e.g., venous ligation, dorsal vein ligation) in men with erectile dysfunction secondary to arteriosclerotic occlusive disease are con-sidered investigational; Topical cream or gel containing vasodilators are considered investigational; Extracorporeal shock wave therapy (ESWT) for Peyronie’s Disease is considered investigational. Revised "Policy Guidelines" section to be consistent with benefit plan limitations. Billing/Coding section: Added the following codes - 37788, 37790, 54360, G0280, J0270, J0275, J2440, J2760, S0090; listed codes 54400-54417 separately; removed code 64999 as it is designated for reporting "unlisted procedures". Notification given 5/27/04. Effective date 7/29/04.
6/16/05 Specialty Matched Consultant Advisory Panel review 5/24/05. Under "When covered" section, deleted statement before #2 - "In the absence of evidence of organic causes for impotence, docu-mentation of a Nocturnal Penile Tumescence test." #2.f re: Penile prosthesis - now includes the requirement that results from Nocturnal Penile Tumescence (NPT) and/or rigidity testing (e.g., Rigi-scan) indicate that the erectile dysfunction is organic and not psychogenic in nature; and that the patient has attempted less invasive therapies (a, b, c, d, and/or e) with failure to have an ade-quate erection. Policy status changed to "Active policy, no longer scheduled for routine literature review." Notice given 6/16/05. Effective date 8/18/05.
Removed deleted code G0280 from Billing/Coding section.
Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are deter-mined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and sub-scriber certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Medical practices and knowledge are constantly changing and BCBSNC reserves the right to review and revise its medical policies periodically.

Source: http://www.askdrkhaled.com/sexual_dysfunction_treatment_male.pdf