CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Nerve Graft with Radical Prostatectomy

Policy on the use of nerve grafting (eg, sural nerve) at the time of radical prostatectomy to reduce postoperative erectile dysfunction; applies to Commercial and Medicare Advantage products administered by Blue Cross & Blue Shield of Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNerve Graft with Radical Prostatectomy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2017

Next Review DateN/A

Key ActionUse CPT 64999 to report the nerve harvest and grafting component and note that prior authorization is not applicable; verify member benefits for coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 RCTrandomized controlled trial identified

Insufficientconclusion on clinical benefit

CPT 64999coding advice

4 centersclinical input centers

Coverage Criteria

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Not Medically Necessary

Not covered when ALL of the following are met:

Not Medically Necessary: Unilateral or bilateral nerve grafting at the time of radical prostatectomy is considered not covered/not medically necessary in individuals who have had resection of one or both neurovascular bundles because the evidence is insufficient to determine clinical benefit.

Supported by randomized controlled trial, cohort studies, and guideline statements noting replacement of resected nerves has not been shown to be beneficial for recovery of erectile function.

Provider Actions

Prior Authorization

Prior authorization: Not applicable.

Note

Benefit Verification

Benefits may vary by contract. Verify the member's benefits, Evidence of Coverage, Subscriber Agreement or Benefit Booklet to determine whether the service is covered or considered not medically necessary for the member's plan.

Documentation Required

Coding/Documentation Note

Use CPT 64999 (unlisted procedure, nervous system) to report the nerve harvest and grafting component of sural nerve grafting of the cavernous nerves because no specific CPT code exists for this anatomic site.

CPT 64999: Unlisted procedure, nervous system

Denial Risk

Coverage Denial Risk

Unilateral or bilateral nerve grafting at the time of radical prostatectomy is considered not covered/not medically necessary when resection of one or both neurovascular bundles occurs; the evidence is insufficient to demonstrate improved health outcomes in this setting.

Background

Erectile dysfunction commonly follows radical prostatectomy, particularly when bilateral neurovascular bundle resection is required. Sural nerve grafting has been proposed to reconstitute cavernous nerve continuity by harvesting an expendable segment of the sural nerve and anastomosing it to the divided cavernous nerve in hopes of restoring spontaneous erections; however, clinical studies including an RCT and observational series have not shown clear benefit.

Definitions

Sural nerve grafting — definition

ProcedureHarvesting a portion of the sural nerve from the leg and anastomosing it to divided ends of the cavernous nerve to attempt restoration of erectile function after radical prostatectomy.

Anatomic sourceSural nerve (harvested from the leg); other donor nerves (e.g., genitofemoral) have been reported.

PurposeTo replace or bridge resected cavernous nerves at time of radical prostatectomy with the goal of restoring spontaneous erections.

Typical technique stepHarvest sural nerve segment, prepare graft, and perform microsurgical anastomosis to the divided ends of the cavernous nerve.

Clinical rationaleSural nerve is expendable and has been widely used in other nerve grafting procedures (e.g., brachial plexus, peripheral nerve injuries).