CAM 20125

Erectile Dysfunction

Category:Laboratory   Last Reviewed:July 2019
Department(s):Medical Affairs   Next Review:July 2020
Original Date:May 1997    

Description:
Erectile dysfunction, also called impotence, is the inability of the male to achieve and/or maintain erection sufficient to enable penetration. Erectile dysfunction can be a secondary symptom of systemic diseases or their treatment (e.g., diabetes mellitus, hypertension, blood lipid abnormalities or peripheral vascular disease). Other causes of erectile dysfunction may be psychogenic in origin or caused by penile trauma, spinal cord injuries, abnormalities of the penis (e.g., penile fibrosis and Peyronie’s disease), veno-occlusive dysfunction or as a result of a radical pelvic surgery (e.g., radical prostatectomy or cystectomy). Alcohol consumption, drugs and smoking may contribute to erectile dysfunction.


Policy:

  1. The following procedures are considered MEDICALLY NECESSARY in the diagnosis of erectile dysfunction:
    • Comprehensive history and physical examination;
    • Nocturnal penile tumescence (NPT) test and rigidity monitoring when psychogenic etiology is suspected;
    • Duplex scan (Doppler and ultrasound) in conjunction with intracorporeal papaverine;
    • Dynamic infusion cavernosogram and cavernosometry;
    • Lab tests:
      • Blood glucose (fasting HbA1c)
      • Complete blood count
      • Creatinine and blood urea nitrogen
      • Hepatic panel
      • Lipid profile
      • Prostate specific antigen
      • Serum testosterone (total/free or bioavailable)
      • Thyroid function studies
      • Urinalysis
    • Pudendal arteriography.
  2. The following test for the diagnosis of erectile dysfunction are considered INVESTIGATIONAL because their effectiveness has not been established
    • Angiotensin-converting enzyme insertion/deletion polymorphism testing
    • Endothelial nitric oxide synthase polymorphism (4 VNTR, G894T, T786C) testing for estimating risk of erectile dysfunction
    • Iron binding capacity
    • Prostatic acid phosphatase

Policy Guidelines:
Lab tests that may be indicated in selected patients are:

  • Morning serum testosterone. If the testosterone level is low, the lab test may be repeated once along with tests for luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin levels to diagnose a pituitary disorder;
  • Complete blood count (CBC);
  • Urinalysis;
  • Creatinine;
  • Lipid profile;
  • Fasting blood sugar (FBS); and
  • Thyroid function studies.

Intracavernous injection therapy is administered via a small, thin needle that is injected into an area along the shaft of the penis known as the corpus cavernosum. The smooth muscle is relaxed, enhancing blood flow and causing erection in 5 to 20 minutes and lasting approximately one hour. It is recommended that the first injection be administered in the physician’s office. Several test injections may be required to establish proper drug dosage.

The NPT test should be administered in a sleep lab.

Cavernosography may be used to indicate arterial and veno-occlusive function abnormality or to differentiate between vascular, neuropathic or psychogenic etiology. More extensive vascular testing may be indicated in young men with a history of pelvic or perineal trauma and who may have anatomic arterial blockage.

Benefit Application
BlueCard®/National Account Issues
Plans may wish to review their contract language on erectile dysfunction to ensure that the contract language is consistent with the Plan’s medical policy on erectile/impotence dysfunction.

Denial of benefits for erectile dysfunction is applicable for contracts or certificates of coverage that maintain an exclusion for the treatment of sexual dysfunctions/inadequacies.

Denial of investigational services is applicable for contracts or certificates of coverage that maintain an exclusion for investigational services.

References:

  1. Dall'era JE, Mills JN, Koul HK, Meacham RB. Penile rehabilitation after radical prostatectomy: Important therapy or wishful thinking? Rev Urol. 2006;8(4):209-215.
  2. Sasso F, Gulino G, Falabella R, et al. Peyronie's disease: Lights and shadows. Urol Int. 2007;78(1):1-9.
  3. Akin-Olugbade Y, Mulhall JP. The medical management of Peyronie's disease. Nat Clin Pract Urol. 2007;4(2):95-103.
  4. Greenfield JM, Shah SJ, Levine LA. Verapamil versus saline in electromotive drug administration for Peyronie's disease: A double-blind, placebo controlled trial. J Urol. 2007;177(3):972-975.
  5. Miles CL, Candy B, Jones L, et al. Interventions for sexual dysfunction following treatments for cancer. Cochrane Database Syst Rev. 2007;(4):CD005504.

Coding Section 

Codes Number Description
CPT 37788 Penile revascularization, artery, with or without vein graft
  37799 Unlisted procedure, vascular surgery (venous ligation for treatment of venous leak impotency)
  54200-54205 Injection procedure for Peyronie’s disease code range
  54230 Cavernosogram
  54231 Cavernosometry (includes intracavernosal injection of vasoactive drugs)
  54235 Injection of corpora cavernosa with pharmacologic agent(s) (e.g., papaverine)
  54250 Nocturnal penile tumescence (NPT) and/or rigidity test
  54400-54401 Insertion of penile prosthesis; non-inflatable
  54405 Insertion of inflatable penile prosthesis, including placement of pump, cylinders, and/or reservoir
  80061 Lipid panel
  80091-80092 Thyroid panel code range
  81002-81005 Urinalysis code range
  81400  Molecular Pathology (Angiotensin-converting enzyme insertion/deletion polymorphism testing) 
  81479 Unlisted molecular pathology procedure (Endothelial nitric oxide synthase polymorphism (4VNTR, G894T, and T786C)  
  82540-82575 Creatinine code range
  83550  Iron binding capacity  
  84402-84403 Testosterone code range
  84066  Phosphatase, acid; prostatic 
  90841-90844 Individual psychotherapy code range
  84439  Thyroxine Free 
  84479  Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) 
  84480 
Triiodothyronine T3; total (TT-3) 
  84481  Triiodothyronine T3 
  84482  Triiodothyronine T3; reverse 
  84520 Urea Nitrogen (BUN) 
  84540  Urea Nitrogen, 24-Hour Urine without Creatinine 
  99204-99205 Physician office visit, comprehensive, new patient code range
  99215 Physician office visit, comprehensive, established patient
ICD-9 Procedure 38.80 Other surgical occlusion of unspecified vessel (includes ligation of blood vessel of penis)
  39.29 Other vascular shunt or bypass (includes arterial penile revascularization)
  64.94 Fitting of external prosthesis of penis
  64.95 Insertion of non-inflatable penile prosthesis
  64.97 Insertion of inflatable penile prosthesis
  89.29 Nocturnal penile tumescence (NPT) test
  94.34 Psychotherapy (individual therapy for psychosexual dysfunction)
  99.29 Injection or infusion of other therapeutic or prophylactic substance (includes administration of vasodilator)
ICD-9 Diagnosis 242.0-242.9 Thyrotoxicosis code range
  244.0-244.9 Hypothyroidism code range
  253.1-253.9 Pituitary dysfunction code range
  255.3-255.9 Adrenal dysfunction code range
  302.72

Psychosexual dysfunction with inhibited sexual excitement (includes impotence)

  607.84 Impotence of organic origin
  V72.6 Admission (outpatient visit) for lab test
HCPCS No Code  
ICD-10-CM (effective 10/01/15) E018 Other iodine-deficiency related thyroid disorders and allied conditions
  E032 Hypothyroidism due to medicaments and other exogenous substances
  E038 Other specified hypothyroidism
  E039 Hypothyroidism, unspecified
  E222 Syndrome of inappropriate secretion of antidiuretic hormone
  E228 Other hyperfunction of pituitary gland
  E229 Hyperfunction of pituitary gland, unspecified
  E230 Hypopituitarism
  E231 Drug-induced hypopituitarism
  E232 Diabetes insipidus
  E233 Hypothalamic dysfunction, not elsewhere classified
  E236 Other disorders of pituitary gland
  E237 Disorder of pituitary gland, unspecified
  E270 Other adrenocortical overactivity
  E271 Primary adrenocortical insufficiency
  E272 Addisonian crisis
  E275 Adrenomedullary hyperfunction
  E278 Other specified disorders of adrenal gland
  E279 Disorder of adrenal gland, unspecified
  E0500 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm
  E0501 Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm
  E0510 Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm
  E0511 Thyrotoxicosis with toxic single thyroid nodule with thyrotoxic crisis or storm
  E0520 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm
  E0521 Thyrotoxicosis with toxic multinodular goiter with thyrotoxic crisis or storm
  E0530 Thyrotoxicosis from ectopic thyroid tissue without thyrotoxic crisis or storm
  E0531 Thyrotoxicosis from ectopic thyroid tissue with thyrotoxic crisis or storm
  E0540 Thyrotoxicosis factitia without thyrotoxic crisis or storm
  E0541 Thyrotoxicosis factitia with thyrotoxic crisis or storm
  E0580 Other thyrotoxicosis without thyrotoxic crisis or storm
  E0581 Other thyrotoxicosis with thyrotoxic crisis or storm
  E0590 Thyrotoxicosis, unspecified without thyrotoxic crisis or storm
  E0591 Thyrotoxicosis, unspecified with thyrotoxic crisis or storm
  E890-E893 Postprocedural hypothyroidism
  E2740 Unspecified adrenocortical insufficiency
  E2749 Other adrenocortical insufficiency
  F5221 Male erectile disorder
  F528 Other sexual dysfunction not due to a substance or known physiological condition
  N529 Male erectile dysfunction, unspecified

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

07/11/2019 

Annual review. Removing verbiage regarding LH, FSH and prolactin testing, as this is addressed in other policies. No other changes made. 

05/28/2019 

Updated category to Laboratory. No other changes. 

07/24/2018 

Annual review, updating coding. No other changes made. (Note: inclusion of a code in a medical policy does NOT indicate it is an allowable service, only that it may be filed in relation to the policy itself.) 

07/17/2017 

Annual review, updating lab testing appropriate for diagnosing this issue. No other changes to policy intent. 

07/03/2017 

Annual review, returning policy to medicine category. No other changes made. 

04/25/2017 

Updated category to Laboratory. No other changes 

05/02/2016 

Annual review, no change to policy intent. 

05/04/2015 

Annual review, no change to policy intent. Added coding and benefit application. 

05/05/2014

Annual Review. No change to content.


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