Penile Prosthesis
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Medical coverage policy governing surgical implantation, removal, and replacement of penile prostheses for treatment of erectile dysfunction for Blue Cross Blue Shield of North Carolina members.
New policy developed and effective 2025-01-01 providing coverage when medical criteria are met.
Related policy reference updated to 'Sex Trait Modification Procedures For Gender Affirming Care'.
Coverage Criteria for Penile Prosthesis
Initial therapy / Implantation
Covered when ALL of the following are met:
All elements required
Removal
Removal may be considered medically necessary for any of the following:
Any one suffices
Replacement
Replacement may be considered medically necessary when:
Replacement follows same criteria as initial implantation
Coverage for penile prosthesis procedures is subject to the member's specific benefit plan. Penile prosthesis may be specifically excluded under some health benefit plans — always verify the Member’s Benefit Booklet before applying this medical policy. When benefits are available, implantation, removal, and replacement are considered under the terms of the member’s plan provisions and this policy's clinical criteria.
Any implantation, removal, or replacement of a penile prosthesis performed when the medical criteria in this policy are not met is considered not medically necessary and will not be covered.
Provider Requirements and Implications
Coverage tied to listed procedure and supply codes
Coverage for implantation, removal, or replacement is tied to the procedure and supply codes listed by the policy; inclusion of a code does not guarantee reimbursement. BCBSNC may request medical records to determine medical necessity.
Conservative therapy must be tried and failed
Prior use and documented failure of less invasive therapies is required before a penile prosthesis is considered medically necessary, unless these therapies are contraindicated.
- Required prior therapies: oral PDE5 inhibitors, vacuum constriction device, intracavernosal injection, intraurethral medications
- Documentation must show trials and failures or documented contraindications to these therapies
Provide complete medical records and clinical documentation
When medical necessity is evaluated, providers should supply a comprehensive history and physical exam, appropriate laboratory testing, and medical records documenting duration and etiology of ED, prior therapies tried and failed, absence of contraindications, and tobacco/nicotine abstinence.
- Document ED duration (at least 6 months) and specified organic etiology (e.g., neurologic, vascular, pelvic trauma, prior pelvic radiation, spinal cord injury/disease, complication of surgery)
- Record trials and failures of listed medical therapies or documented contraindications
- Document absence of systemic, urogenital, or regional skin infection and tobacco/nicotine abstinence for at least 6 weeks prior to surgery
- Letters of support/explanation are useful but insufficient unless they include all specific information requested
Denial risk if medical criteria are unmet
Services for implantation, removal, or replacement will be denied as not medically necessary if the policy's stated medical criteria are not met.
- All primary coverage criteria must be met (including 6-month ED duration, specified organic causes, failed prior therapies or contraindications, absence of contraindications, and tobacco/nicotine abstinence) or the service is not covered
Applicable Procedure and Supply Codes
Background and Rationale
Erectile dysfunction (ED) is the inability to achieve and/or maintain a penile erection sufficient for satisfactory sexual performance and increases in prevalence with age. ED is frequently associated with medical conditions such as hypertension, ischemic heart disease, and diabetes, and may result from neurologic or vascular disease, pelvic trauma, prior pelvic surgery or radiation, or spinal cord injury. When less invasive therapies (for example, oral PDE5 inhibitors, vacuum constriction devices, intracavernosal injection, or intraurethral medications) have failed or are contraindicated, surgical implantation of a penile prosthesis — either a semi-rigid rod or an inflatable device with cylinders, reservoir, and pump — is an established treatment option for patients with organic ED who meet the policy's criteria.
Key Definitions
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