CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Nerve Grafting at Time of Radical Prostatectomy

This policy addresses unilateral or bilateral nerve grafting (commonly sural nerve grafting) performed at the time of radical prostatectomy to restore erectile function, and the coverage stance for Medicare Advantage and commercial products under Blue Cross Blue Shield - Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNerve Grafting at Time of Radical Prostatectomy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFor coding and billing, report the procedure using CPT 64999 (unlisted procedure, nervous system) and note that prior authorization is not applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredMedicare Advantage

Not medically necessaryCommercial

No specific CPTCPT availability

4 centersClinical input

Coverage determinations

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNerve Grafting at Time of Radical Prostatectomy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFor coding and billing, report the procedure using CPT 64999 (unlisted procedure, nervous system) and note that prior authorization is not applicable.

SourceLink

On This Page

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Medicare Advantage: Unilateral or bilateral nerve graft is considered not covered in individuals who have had resection of one or both neurovascular bundles as part of a radical prostatectomy as the evidence is insufficient to determine the effects of the technology on health outcomes.

Commercial Products: Unilateral or bilateral nerve graft is considered not medically necessary in individuals who have had resection of one or both neurovascular bundles as part of a radical prostatectomy as the evidence is insufficient to determine the effects of the technology on health outcomes.

Unilateral or bilateral nerve grafting performed after resection of one or both neurovascular bundles during radical prostatectomy is not supported by sufficient evidence to demonstrate a net health benefit. As a result, such procedures are excluded from coverage or considered not covered / not medically necessary under the terms described below, depending on product.

Key point: When neurovascular bundles are resected as part of radical prostatectomy, claims for subsequent unilateral or bilateral nerve grafting to restore erectile function may be denied because evidence is insufficient to determine effects on health outcomes.

Provider actions, billing, and alternatives

Prior Authorization

Prior authorization is not required for nerve grafting procedures.

PA not applicable

Note

Noninvasive Treatment Alternatives

Noninvasive treatment alternatives should be considered and documented before surgical grafting. Options include vacuum constriction devices and intracavernosal injection therapy; spontaneous erectile activity is preferred by patients when possible. Discuss these alternatives and prior attempts with the patient in the medical record.

Vacuum constriction devices
Intracavernosal injection therapy
Document prior noninvasive therapy attempts and patient preference

Billing Rule

Coding and Billing Guidance

There is no specific CPT code for cavernous nerve (sural) grafting. Use CPT 64999 (unlisted procedure, nervous system) to report the nerve harvest and grafting component and document the rationale for the unlisted code in the operative report.

Use CPT 64999 for nerve harvest and grafting of cavernous nerves
Include clear operative documentation describing procedure performed and justification for unlisted code

Denial Risk

Coverage Denial Risk

Coverage for nerve grafting after resection of one or both neurovascular bundles during radical prostatectomy is at high risk for denial: evidence is insufficient to demonstrate clinical benefit in this population. Highlight this when submitting claims and include detailed clinical rationale if pursuing coverage.

Unilateral or bilateral nerve grafting following resection of one or both neurovascular bundles is considered not covered / not medically necessary by plan policy
Provide comprehensive clinical documentation if requesting exception or review

Clinical background

Erectile dysfunction is a common consequence of radical prostatectomy, particularly when one or both neurovascular bundles are resected. Surgical techniques such as sural (or other) nerve grafting have been proposed to restore cavernous nerve continuity and recover erectile function, but clinical studies have not established consistent benefit.

Because randomized and observational evidence to date is insufficient to demonstrate improved potency or other meaningful health outcomes after nerve grafting at the time of prostatectomy, payers have determined the intervention remains investigational. This rationale underlies the product-specific determinations that unilateral or bilateral nerve grafting following neurovascular bundle resection is either not covered (Medicare Advantage) or considered not medically necessary (Commercial Products).

Key definitions

Sural nerve grafting (cavernous nerve graft) — definition and procedural summary

DefinitionHarvesting a segment of the sural nerve (or other expendable sensory nerves) and anastomosing it to the divided ends of the cavernous nerves during radical prostatectomy to attempt to restore erectile function.

Anatomic sourceSural nerve harvested from one leg; other nerves (eg, genitofemoral) have also been used in reports.

Procedure steps (brief)Portion of sural nerve is harvested, prepared, and microsurgically anastomosed to the proximal and distal ends of the resected cavernous nerve during prostatectomy.

Intended goalTo replace resected cavernous nerves and restore spontaneous erectile function after radical prostatectomy.

Clinical evidence summaryRandomized controlled trial and cohort studies did not demonstrate improved potency rates; overall evidence is insufficient to show improved net health outcomes.

OpenPayer

Nerve Grafting at Time of Radical Prostatectomy

Coverage determinations

Procedure coding

Provider actions, billing, and alternatives

Clinical background

Key definitions