Prior authorization required for penile implant procedures

Preauthorization is required for penile implant procedures. Submit a prior authorization request that includes clinical evidence supporting medical necessity for the procedure and the CPT code(s) being requested (e.g., 54400, 54401, 54405, 54408, 54410, 54411, 54416, 54417).

• Prior authorization must accompany clinical evidence demonstrating medical necessity.
• Include the applicable CPT code(s) for the planned procedure.

Document failure or contraindication of conservative therapies

Documentation must demonstrate failure of, or a contraindication to, conservative/alternatives therapies before penile implant coverage is approved for organic erectile dysfunction.

• Examples of alternatives: PDE‑5 inhibitors, vacuum devices, intracavernosal (intracavernous) injections.
• For organic conditions not listed, documentation must indicate all other failed treatment modalities.

Treating physician/PCP must submit clinical evidence

The treating physician or primary care provider must submit clinical evidence showing the member meets the medical necessity criteria for the procedure, including documentation of failed or contraindicated alternative therapies or listed causal conditions.

• Provide clinical records that document the causal condition(s) or prior treatment failures.
• Include any operative indications or clinical notes relevant to meeting coverage criteria.

Risk of denial if required evidence is not provided

Failure to submit the required clinical evidence will prevent EmblemHealth from properly reviewing the preauthorization or post-payment request and may result in denial.

• Ensure all requested documentation is included with the authorization or post‑payment submission to avoid denial.