CurrentUnitedHealthcarePolicy BIP161.O

Sexual Dysfunction (benefit interpretation)

Defines covered diagnostic services and select treatments for sexual dysfunction and lists excluded devices, procedures, medications, and supplies; coverage is subject to member's Evidence of Coverage/Schedule of Benefits and state/federal mandates.

Policy Summary

PayerUnitedHealthcare

PolicySexual Dysfunction (benefit interpretation)

Policy CodePolicy BIP161.O

Change TypeRoutine review; no change

Effective DateJun 1, 2026

Next Review Date

Key ActionRefer to the member's Evidence of Coverage (EOC) or Schedule of Benefits (SOB) to determine coverage eligibility for diagnostic services, treatments, and supplemental outpatient drug benefits.

POLICY UPDATE CHANGES

Routine review; no change to coverage guidelines

4Diagnostic services listed

1Therapeutic injection type covered

7Not-covered examples

Coverage Summary

This policy (Policy Number BIP161.O) provides benefit interpretation for sexual dysfunction services and became effective on June 1, 2026. The coverage stance for the policy is mixed, reflecting that some diagnostic services and select treatments are covered while specific devices, procedures, and medications are excluded. The policy is current as of the effective date and references routine review with prior version archived.

Medical-Necessity Criteria

Covered Benefits - Diagnostic and Treatment Services

Covered when ALL of the following are met:

ALL of the following

Services are listed in Federal/State Mandated Regulations, State Market Plan Enhancements, or Covered Benefits sections
Service is medically necessary
Coverage eligibility is determined by the member's Evidence of Coverage (EOC) or Schedule of Benefits (SOB)
Diagnostic services (any of the following)
- Medical history and physical exam (including sexual history and psychosocial evaluation)
- Routine laboratory services, including measurement of: Serum testosterone, Gonadotropin levels, Serum prolactin, Thyroxin
- Nocturnal penile tumescence testing
- Psychiatric evaluation when appropriate
Testosterone injections for documented low testosterone levels
Coverage may be available for treatment of sexual dysfunction related to medically necessary mental health care services and substance-related and addictive disorders (refer to EOC/SOB)

Not Covered / Exclusions

Not Covered

The following are not covered for sexual dysfunction:

ALL of the following

External vacuum devices, pumps, or constriction rings (e.g., ErecAid)
Surgical procedures, including penile revascularization and implantation of penile prosthesis (e.g., FlexiRod)
Prescription or injectable medications, including but not limited to: Alprostadil urethral suppository (MUSE), Viagra, Testosterone patches, Caverject, Papaverine, Regitine

Provider Actions

Documentation Required

Determine coverage via member documents

Providers must refer to the member's Evidence of Coverage (EOC) or Schedule of Benefits (SOB) to determine coverage eligibility for diagnostic services, treatments, and supplemental outpatient drug benefits.

Prior Authorization

Prior authorization where applicable per EOC/SOB

If the member's plan requires prior authorization for specific drugs or procedures for sexual dysfunction, providers must obtain authorization per the member's EOC/SOB and applicable state/federal mandates.

Documentation Required

Medical necessity documentation

All services must be medically necessary and supported by documentation (e.g., laboratory results showing low testosterone for testosterone injections).

Background

Policy background: This document outlines how benefits for sexual dysfunction services are interpreted. Coverage is governed by applicable federal and state mandates, any State Market Plan Enhancements, and the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB), which will determine coverage eligibility for diagnostic services, treatments, and any supplemental outpatient drug benefits. All services must be medically necessary and supported by documentation (for example, laboratory results demonstrating low testosterone for testosterone injections). The policy lists covered diagnostic services and select treatments and explicitly identifies excluded items such as external vacuum devices, certain surgical procedures, and specific prescription or injectable medications.