RetiredCapital BluecrossPolicy MP 2.016

Erectile Dysfunction

Defines medically necessary, not medically necessary, investigational procedures and coverage criteria for diagnosis and treatment of erectile dysfunction for Capital Blue Cross products; includes product variations, coding guidance, and policy history. The policy was retired effective 2024-07-01.

Policy Summary

PayerCapital Bluecross

PolicyErectile Dysfunction

Policy CodePolicy MP 2.016

Change TypeRetired

Effective DateRETIRED 7/1/2024

Next Review Date

Key ActionDocument that the patient is ≥18, underlying causes have been evaluated/treated, there is no symptomatic or untreated hypogonadism/hyperprolactinemia, and ED is determined to be organic to support medically necessary treatments.

POLICY UPDATE CHANGES

Policy retired effective 7/1/2024 (retirement noted 02/08/2024).

Code 0864T added (admin update 12/13/2023; effective 1/1/24).

02/02/2023 minor review: formatting updates, additional criteria for penile revascularization, and 3 new treatments listed in investigational statement.

02/01/2021 added CPT (36245-36248 & 75736), HCPCS (J0270, J0275, & L7902), and Dx (N52.8 & N52.9) codes; deleted CPT 54230 & 54231.

3Diagnostic procedures considered medically necessary

3Diagnostic procedures considered not medically necessary

5Treatments considered medically necessary

Coverage summary

Scope: Defines medically necessary, not medically necessary, and investigational procedures and coverage criteria for diagnosis and treatment of erectile dysfunction (ED) for Capital Blue Cross products. Policy number: MP 2.016. Status: RETIRED with retirement effective date 7/1/2024 (retirement noted 02/08/2024). Last review date: 2024-02-08. Evidence references include the American Urological Association Erectile Dysfunction Management Guideline 2018 as the rationale source.

Policy metadata

Policy numberMP 2.016

StatusRETIRED

Last review2024-02-08

Retirement effective date2024-07-01

Scope summaryDefines medically necessary, not medically necessary, and investigational diagnostic procedures and treatments for erectile dysfunction for Capital Blue Cross products; includes coverage criteria, coding guidance, and policy history. Penile arterial revascularization is limited to select younger men without generalized vascular disease and with focal arterial injury.

Diagnostic procedures — coverage criteria

Diagnosis — medically necessary procedures

The following procedures may be considered medically necessary in individuals with the diagnosis of erectile dysfunction (ED):

ANY of the following

Duplex scans (Doppler and ultrasound) in conjunction with intracorporeal papaverine.
Nocturnal penile tumescence (NPT) test and rigidity monitoring.
Pudendal arteriography.

Duplex scans (Doppler and ultrasound) in conjunction with intracorporeal papaverine.; Nocturnal penile tumescence (NPT) test and rigidity monitoring.; Pudendal arteriography.

Treatment — medical necessity criteria and covered treatments

Treatment — general medical necessity criteria

Treatment of erectile dysfunction may be considered medically necessary when ALL of the following are met

ALL of the following

Individual is age ≥18.
Evaluation and treatment for underlying disease or condition that may be causing ED has been completed.
No evidence of symptomatic or untreated hypogonadism or hyperprolactinemia.
The condition has been determined to be the result of, or related to, an organic disease or injury.

Investigational or not covered treatments and diagnoses

Treatments considered investigational / not covered

The following are considered investigational in the treatment of erectile dysfunction:

ANY of the following

Application of topical cream or gel containing vasodilators.
Arterial (penile) revascularization, except as listed under medically necessary criteria.
Venous ligations in the treatment of venous leak impotency.
Extracorporeal shock wave therapy (ESWT).

Coding guidance

Covered when medically necessary - Procedure / HCPCS / othermixedCovered

54240	Procedure Code (listed in table)
54250	Procedure Code (listed in table)
54400	Procedure Code (listed in table)
54401	Procedure Code (listed in table)
54405	Procedure Code (listed in table)
54406	Procedure Code (listed in table)
54408	Procedure Code (listed in table)
54410	Procedure Code (listed in table)
54411	Procedure Code (listed in table)
54415	Procedure Code (listed in table)

1–10 of 18

1/2

Administrative history notes: Code 0864T was added via an administrative update on 12/13/2023 and is effective 1/1/2024. The policy history also documents the 02/01/2021 code changes that added CPT codes 36245–36248 & 75736, HCPCS codes J0270, J0275, & L7902, and diagnosis codes N52.8 & N52.9, and deleted CPT codes 54230 & 54231. The coding table in the policy consolidates current coding consistent with the policy history.

Provider actions and documentation requirements

Documentation Required

Medical necessity documentation for treatment

Document that the patient is age 18 or older; that evaluation and treatment for underlying disease or conditions potentially causing erectile dysfunction have been completed; there is no evidence of symptomatic or untreated hypogonadism or hyperprolactinemia; and that the erectile dysfunction has been determined to be the result of, or related to, an organic disease or injury.

Documentation Required

Penile arterial revascularization eligibility documentation

Document that the patient is a nonsmoker; that corporeal venous function is normal; that there is no evidence of generalized vascular disease (including, but not limited to, diabetes mellitus, hypertension, coronary artery disease), Peyronie's plaques, intracavernosal masses, nodules, or sensory neuropathy; that erectile dysfunction is secondary to a focal arterial occlusion demonstrated by arteriography or duplex ultrasonography; and that the arteriogenic erectile dysfunction is secondary to pelvic or perineal trauma.

Background and guideline references

Background: Erectile dysfunction (ED) is defined as the inability to develop and maintain an erection for satisfactory sexual intercourse or activity and may be organic, psychogenic, or secondary to systemic disease or trauma. Diagnostic evaluation options noted include duplex (Doppler) ultrasound with intracavernosal injection, nocturnal penile tumescence (NPT) testing, and pudendal arteriography; some tests (eg, cavernosal electromyography, dorsal nerve conduction studies) are considered not medically necessary. Treatment options range from conservative/non‑surgical therapies (vacuum erection devices, intraurethral alprostadil, intracavernous vasoactive injections) to surgical options (penile prostheses). The policy references the AUA guideline and emphasizes that penile arterial revascularization is limited to select younger men without generalized vascular disease and with focal arterial injury, and should be performed only by highly skilled surgeons in appropriate centers.

Evidence: Guideline source: American Urological Association Erectile Dysfunction Management Guideline 2018. Additional supporting references cited in the policy include clinical reviews and guideline documents (examples: UpToDate topics on erectile dysfunction and surgical treatment, EAU guidelines, and peer‑reviewed literature listed in the References section).

Definitions

Term	Definition
ALPROSTADIL	A synthetic prostaglandin used to treat erectile dysfunction.
INTRACAVERNOUS VASOACTIVE INJECTION THERAPY	Injection of papaverine, phentolamine, and/or prostaglandin E1 (alprostadil) into the corpus cavernosum via a needle to relax smooth muscle and increase blood flow, producing an erection within five to twenty minutes.
PENILE PROSTHESIS	A device implanted in the penis that enables it to become erect; used in patients with organic erectile dysfunction to maintain an erection (types include semirigid and inflatable implants).

Revision history

2024-07-01retiredLatest

Policy retired effective 7/1/2024 (retirement noted 02/08/2024).

2023-12-13admin update

Administrative update adding new code 0864T (noted 12/13/2023; code effective 1/1/2024).

2023-02-02minor review (material)

Minor review with formatting updates, additional criteria for penile revascularization, and three new treatments added to the investigational statement (02/02/2023).

Treatments considered medically necessary (when general criteria met)

The following treatments are considered medically necessary for erectile dysfunction when the above criteria is met:

ANY of the following

Intraurethral insertion of the prostaglandin alprostadil.
Intracavernous vasoactive drug injection therapy with papaverine, phentolamine, and/or prostaglandin E1 (alprostadil).
Vacuum erection assistance devices.
Penile prosthetic implants when non-invasive forms of therapy have failed, are contraindicated, or are not tolerated.
Penile arterial revascularization (required ALL):
- Individual is a nonsmoker.
- Corporeal venous function is normal.
- There is no evidence of generalized vascular disease (including, but not limited to: diabetes mellitus, hypertension, coronary artery disease), Peyronie's plaques, intracavernosal masses, nodules, or sensory neuropathy.
- Erectile dysfunction is secondary to a focal arterial occlusion as evidenced by arteriography or duplex ultrasonography.
- Arteriogenic erectile dysfunction is secondary to pelvic or perineal trauma.

Intraurethral insertion of the prostaglandin alprostadil.; Intracavernous vasoactive drug injection therapy with papaverine, phentolamine, and/or prostaglandin E1 (alprostadil).; Vacuum erection assistance devices.; Penile prosthetic implants when non-invasive forms of therapy have failed, are contraindicated, or are not tolerated.; Penile arterial revascularization (required ALL): Individual is a nonsmoker.; Corporeal venous function is normal.; There is no evidence of generalized vascular disease (including, but not limited to: diabetes mellitus, hypertension, coronary artery disease), Peyronie's plaques, intracavernosal masses, nodules, or sensory neuropathy.; Erectile dysfunction is secondary to a focal arterial occlusion as evidenced by arteriography or duplex ultrasonography.; Arteriogenic erectile dysfunction is secondary to pelvic or perineal trauma.

0232T	Investigational procedure code (mapped to 0101T / 0864T in table)
0101T	Investigational procedure code (listed as equivalent to 0232T)
0864T	Investigational procedure code (added effective 1/1/24 per history)

N48.6	Induration penis plastica.
N48.82	Acquired torsion of penis.
N48.83	Acquired buried penis.
N48.89	Other specified disorders of penis.
N52.01	Erectile dysfunction due to arterial insufficiency.
N52.02	Corporo-venous occlusive erectile dysfunction.
N52.03	Combined arterial insufficiency and corporo-venous occlusive erectile dysfunction.
N52.1	Erectile dysfunction due to diseases classified elsewhere.
N52.2	Drug-induced erectile dysfunction.
N52.31	Erectile dysfunction following radical prostatectomy.