Penile Prosthesis Implantation Secondary to Erectile Dysfunction (ED)
Customize your policy alerts
Sign up for metroplushealth Policy UM-MP238 alerts
Get alerted when Policy UM-MP238 changes without checking for updates manually.
Monitor payer policy activity
This policy governs medical necessity criteria, coding, and coverage limitations for penile prosthesis implantation for erectile dysfunction (ED) for MetroPlus Health Plan beneficiaries across listed lines of business.
No material clinical or coverage changes in this revision.
Coverage Criteria for Penile Prosthesis Implantation
Additional considerations and device management
Guidance on special populations and device removal/reimplantation.
The Medicaid program prohibits coverage of drugs used for the treatment of sexual or erectile dysfunction unless those drugs are being used to treat another FDA‑approved condition. Examples of medications noted in the source include alprostadil (Caverject/MUSE), sildenafil (Viagra), testosterone patches, papaverine, and phentolamine; such agents are excluded from coverage for ED unless prescribed for an alternate FDA‑approved indication (for example, pulmonary hypertension).
This prohibition follows federal guidance on excluded categories for prescription drug benefits and aligns MetroPlus policy with the Medicaid/Medicare Prescription Drug Benefit Manual regarding ED drugs when not used for other approved indications.
Per New York State Medicaid guidance, convicted sex offenders are not eligible for coverage of erectile dysfunction drugs, procedures, or supplies under the Medicaid program. Prior approval is still required for the listed CPT/HCPCS procedure codes when applicable, but coverage for these members is explicitly excluded.
Coverage determinations are subject to the definitions and exclusions of each specific benefit program. Even when MetroPlus determines a service or supply is medically necessary under this policy, that determination does not guarantee coverage or payment if the member’s benefit program excludes the service or a governing legal requirement mandates exclusion. In cases of discrepancy, the member’s benefit program and applicable legal requirements will govern.
Implantable penile prostheses are considered experimental and investigational when used for indications other than those specifically listed in this policy because effectiveness for other indications has not been established. Use of these devices outside the policy‑specified indications is therefore not supported by MetroPlus clinical criteria.
Procedure, Device, and Diagnosis Codes
| 37788 | Penile revascularization, artery, with or without vein graft. |
| 37790 | Penile venous occlusive procedure. |
| 54400 | Insertion of penile prosthesis; non-inflatable (semi-rigid). |
| 54401 | Insertion of penile prosthesis, inflatable (self-contained). |
| 54405 | Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir. |
| 54408 | Repair of component(s) of a multi-component, inflatable penile prosthesis. |
| 54410 | Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session. |
| 54411 | Removal and replacement of all components of a multi-component, inflatable penile prosthesis through an infected field at the same operative session. |
| 54416 | Removal and replacement of non-inflatable (semi-rigid) or inflatable penile prosthesis at the same operative session, including irrigation and debridement of infected tissue. |
| J0270 | Injection, alprostadil, 1.25 mcg (aka Caverject). |
| J0275 | Alprostadil urethral suppository (aka MUSE). |
| J2440 | Injection, papaverine hcl, up to 60 mg. |
| J2760 | Injection, phentolamine mesylate, up to 5 mg. |
| L7900 | Vacuum erection system. |
| F52.0 | Hypoactive sexual desire disorder. |
| F52.21 | Male erectile disorder. |
| F52.32 | Male orgasmic disorder. |
| 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. |
| N52.32 | Erectile dysfunction following radical cystectomy. |
| 0VUSX7Z | Supplement Penis with Autologous Tissue Substitute, External Approach. |
| 0VUSXJZ | Supplement Penis with Synthetic Substitute, External Approach. |
| 0VUSXKZ | Supplement Penis with Nonautologous Tissue Substitute, External Approach. |
| 0VUS0JZ | Supplement Penis with Synthetic Substitute, Open Approach. |
| 0VUS4JZ | Supplement Penis with Synthetic Substitute, Percutaneous Endoscopic. |
Provider Actions, Prior Authorization, and Documentation Requirements
Prior authorization required for listed procedure codes
Prior authorization (prior approval) is required for the listed CPT/HCPCS procedure codes related to penile prosthesis implantation and related procedures; note that Medicaid restrictions apply for convicted sex offenders.
Prior authorization requires clinical evidence
MetroPlus requires submission of clinical evidence showing the patient meets the policy criteria as part of any prior authorization request; without this documentation MetroPlus cannot properly review or authorize the request.
- Clinical evidence must demonstrate the patient meets the policy's medical necessity criteria.
- Lack of submitted evidence will prevent proper review of the prior authorization request.
Conservative therapy prerequisite — document failed nonsurgical methods
Document that nonsurgical therapies have been tried and proven ineffective, or are contraindicated, before requesting penile prosthesis implantation authorization.
- Policy criterion: “Nonsurgical methods have proven ineffective or are contraindicated.”
Treating physician/PCP must submit clinical evidence
The treating physician or primary care provider must submit MetroPlus Health Plan clinical evidence that the patient meets the policy criteria to allow prior authorization review.
- Submission must come from the treating physician or PCP and include supporting clinical documentation.
- Without this information MetroPlus will not be able to properly review the prior authorization request.
Physician must submit supporting clinical evidence
The treating physician or primary care provider is responsible for providing clinical documentation to support the request for treatment or surgery under this policy.
- Clinical evidence should specifically demonstrate how the patient satisfies the policy’s listed criteria.
- Failure to provide this documentation will impede review of the request.
Denial risk if clinical evidence not submitted
Failure to submit the required clinical evidence that the patient meets the policy criteria will prevent MetroPlus from properly reviewing the prior authorization and may result in denial.
- “Without this documentation and information, Metroplus Health Plan will not be able to properly review the request for prior authorization.”
- Lack of submitted clinical evidence may result in denial.
Approval prevented without submission of clinical evidence
If the treating physician or PCP does not submit MetroPlus Health Plan clinical evidence that the patient meets the criteria, the prior authorization request cannot be properly reviewed and approval will be prevented.
- Submission of clinical evidence is a required part of the prior authorization process.
- Failure to submit required evidence will prevent approval and may lead to denial.
Definitions
Background
Erectile dysfunction (ED) is the inability to attain or maintain an erection sufficient for satisfactory sexual performance. Penile prosthesis implantation is a surgical treatment option for documented physiologic ED when nonsurgical therapies have proven ineffective or are contraindicated and when specific clinical and laboratory criteria are met.
Additional considerations include candidacy for inflatable prosthesis in patients with sickle cell disease and stuttering priapism or cavernosal scarring, selection of patients without diabetes or neurologic disease to optimize outcomes, and recognition that removal of a penile implant is medically necessary for infection, intractable pain, mechanical failure, or urinary obstruction. Reimplantation may be medically necessary when prior removal was for a medically necessary indication and the patient continues to meet policy criteria.
MetroPlus established these criteria based on review of clinical outcome studies, regulatory status, evidence‑based guidance, and expert clinical input. Providers must follow the policy’s medical necessity requirements and the member’s specific benefit program when seeking prior authorization and coverage.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.