CurrentUnitedHealthcarePolicy BIP161.N

Sexual Dysfunction — Diagnostic Evaluation and Treatment Coverage

Defines UnitedHealthcare coverage stance for diagnostic evaluation and certain treatments for sexual dysfunction, and lists devices, procedures, and drugs that are not covered; applies to members under UnitedHealthcare West plans and refers to members' Evidence of Coverage for specific eligibility.

Policy Summary

PayerUnitedHealthcare

PolicySexual Dysfunction — Diagnostic Evaluation and Treatment Coverage

Policy CodePolicy BIP161.N

Change TypeRoutine reviewclarified — no change to coverage

Effective DateJun 1, 2025

Next Review Date

Key ActionCheck the member's Evidence of Coverage/Schedule of Benefits for prior authorization and eligibility before providing services.

SourceLink

POLICY UPDATE CHANGES

Routine review; no change to coverage guidelines.

DiagnosticDiagnostic services listed

Testosterone injectionsCovered treatment

Multiple exclusionsNot covered examples

Drugs listedPrescription medications mentioned

Coverage Criteria

Covered services

Covered when ALL of the following are met

Diagnostic evaluation: Medical history and physical exam including sexual history and psychosocial evaluation; routine laboratory services including measurement of serum testosterone, gonadotropin levels, serum prolactin, and thyroxin; nocturnal penile tumescence testing; psychiatric evaluation when appropriate.

Refer to the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB) for plan-specific eligibility, limitations, and prior authorization requirements.

Treatment for low testosterone: Testosterone injections for documented low testosterone levels.documented low testosterone

All services must be medically necessary and subject to plan provisions in the member's EOC/SOB; verify prior authorization if required.

Examples of devices and procedures specifically excluded from coverage include external vacuum devices, pumps, or constriction rings (for example, ErecAid) and surgical interventions such as penile revascularization and implantation of a penile prosthesis (for example, FlexiRod).

Policy Summary

PayerUnitedHealthcare

PolicySexual Dysfunction — Diagnostic Evaluation and Treatment Coverage

Policy CodePolicy BIP161.N

Change TypeRoutine reviewclarified — no change to coverage

Effective DateJun 1, 2025

Next Review Date

Key ActionCheck the member's Evidence of Coverage/Schedule of Benefits for prior authorization and eligibility before providing services.

SourceLink

On This Page

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Provider Actions and Requirements

Step Therapy

Drug benefit verification

Verify drug benefit and EOC/SOB. Members may have supplemental outpatient prescription coverage for drugs for sexual dysfunction; coverage, step therapy, and prior authorization requirements vary by plan. Refer to the member's Evidence of Coverage (EOC) or Schedule of Benefits (SOB) before prescribing or billing.

Check member EOC/SOB for supplemental outpatient drug benefit for sexual dysfunction medications
Verify prior authorization and step therapy requirements for prescription or injectable medications (e.g., sildenafil/Viagra, alprostadil, testosterone formulations)
Drug benefit may be under a separate pharmacy benefit — confirm pharmacy vs medical coverage

Documentation Required

Required clinical documentation

Required clinical documentation for diagnostic and treatment services. Submit complete clinical records to support medical necessity, including medical/sexual/psychosocial history, physical exam findings, and relevant laboratory results.

Medical history and physical exam, including sexual history and psychosocial evaluation
Relevant laboratory tests: serum testosterone, gonadotropin levels, serum prolactin, thyroxine
Nocturnal penile tumescence testing when performed
Psychiatric evaluation documentation when applicable
Documentation of prior conservative therapies and rationale for invasive or excluded treatments (if applicable)

Denial Risk

Denial risks for excluded services

Denial risks for excluded services. Claims for excluded items, procedures, and supplies are at high risk for denial when billed or requested for coverage; review the member's EOC/SOB and the plan exclusions prior to authorization or claim submission.

External vacuum devices, pumps, and constriction rings (e.g., ErecAid) — not covered
Surgical procedures such as penile revascularization — not covered
Implantation of penile prosthesis (e.g., FlexiRod) — not covered
Claims for excluded devices or surgical/prosthetic interventions will be denied unless EOC/SOB explicitly states coverage

OpenPayer

Sexual Dysfunction — Diagnostic Evaluation and Treatment Coverage

Coverage Criteria

Provider Actions and Requirements

Background

Definitions