Nerve Graft with Radical Prostatectomy
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This policy governs prior authorization and coverage determinations for unilateral or bilateral nerve grafting performed with radical prostatectomy for erectile dysfunction, and applies to Baylor Scott & White Health Plan members unless superseded by plan documents or applicable Medicare/Medicaid mandates.
No material clinical or coverage changes in this revision.
Coverage Determinations
Experimental/Investigational
Covered when ALL of the following are met:
Includes sural nerve grafts and other nerve grafts applied at time of prostatectomy.
Conservative alternatives
Context and alternatives
Documentation of prior conservative therapy may be considered in evaluations.
The following procedure and supply codes are identified in the policy as not covered when billed for nerve grafting in association with radical prostatectomy: CPT codes 64910, 64911, 64912, 64913, 64999, and HCPCS codes C9352, C9353, C9355, C9361. Example diagnosis codes called out in the policy include ICD-10 codes N52.01 (male erectile dysfunction following radical retro-pubic prostatectomy) and N52.9 (male erectile dysfunction).
BSWHP considers unilateral or bilateral nerve grafting performed at the time of radical prostatectomy to be experimental/investigational and not medically necessary because there is a paucity of peer‑reviewed literature demonstrating efficacy. This stance includes sural nerve grafts and other nerve graft techniques and applies to adjunctive collagen nerve grafts/wraps (for example, Avance®, Axogen 2 Nerve Wrap, Integra NeuralWrap™, and various collagen nerve cuff/wraps), which the policy identifies as unproven for all indications.
CPT, HCPCS, and ICD-10 Coding
| N52.01 | Male erectile dysfunction following radical retro-pubic prostatectomy |
| N52.9 | Male erectile dysfunction |
Prior Authorization & Provider Requirements
Prior authorization required for nerve graft with radical prostatectomy
Prior authorization is required for nerve graft procedures performed in association with radical prostatectomy; several CPT and HCPCS codes related to these procedures are listed in the policy and should be addressed in PA submissions.
- Policy header: PRIOR AUTHORIZATION: Required
- PA applies to nerve graft in association with radical prostatectomy and to listed CPT/HCPCS codes
Document conservative, noninvasive alternatives first
Noninvasive conservative treatments are available and are described as alternatives to nerve grafting; document use of these options when relevant to medical necessity evaluations.
- Vacuum constriction devices
- Intracavernosal (intra-cavernosal) injection therapy
- Note: spontaneous erectile activity is preferred by patients; documentation of prior conservative therapy may be considered
Include clinical rationale and supporting literature with PA request
Submit a prior authorization request per plan procedures and include the clinical rationale and any supporting literature or evidence to justify the procedure; refer to applicable plan EOC/SPD and Medicare/Medicaid guidance where relevant.
- Include clinical rationale describing why conservative alternatives are insufficient if applicable
- Attach peer‑reviewed literature or evidence supporting surgical nerve grafting when available
Denial risk: procedure considered experimental/investigational
Nerve grafting (unilateral or bilateral) for erectile dysfunction after radical prostatectomy is considered experimental/investigational; claims for these services are at risk of denial for medical necessity.
- Policy states BSWHP considers unilateral or bilateral nerve graft experimental and investigational due to limited peer‑reviewed evidence
- Includes sural nerve grafts and other nerve grafts applied at time of prostatectomy
Coding-based denial risk: listed CPT/HCPCS/ICD‑10 codes not covered
Specified CPT, HCPCS, and example ICD‑10 diagnosis codes are listed as not covered in the policy and may lead to claim denial if billed for these services.
Clinical Background
Erectile dysfunction is a common sequela of radical prostatectomy, particularly when one or both neurovascular bundles are resected. Surgical approaches such as sural nerve grafting—harvesting a segment of the sural nerve and anastomosing it to divided cavernous nerve ends—have been attempted to restore erectile function, and a variety of nerve wraps and graft materials have been described. However, available data on long‑term outcomes are limited and insufficient to demonstrate effectiveness, which underpins the policy’s noncoverage determination and coding exclusions.
Definitions
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