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Evaluation and Treatment of Erectile Dysfunction (ED)
MA11.079e

Policy

This policy uses coverage criteria primarily based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents. In the absence of fully established coverage criteria from these Medicare coverage documents for a specific medical service or item, the criterion/indication/service indicated by an asterisk below (*) is based on internal coverage criteria developed by the Company in consideration of peer-reviewed medical literature, clinical practice guidelines, regulatory status, and/or expert opinion. 

DIAGNOSIS OF ERECTILE DYSFUNCTION (ED)

MEDICALLY NECESSARY
The following procedures are considered medically necessary and, therefore, covered for the diagnosis of ED:
  • Comprehensive history and physical examination
  • Duplex scan
  • Dynamic infusion cavernosogram and cavernosometry
  • Laboratory testing for evaluation of hormone levels (e.g., serum testosterone, prolactin)
    • Abnormal hormone levels indicate further endocrine testing for pituitary, thyroid, and adrenal dysfunction
  • Nocturnal penile tumescence (NPT) test, when results from the physical examination cannot be used to distinguish between organic causes and psychogenic causes
  • Pudendal arteriography
  • Pharmacological response test for ED. (Note: The drugs associated with the pharmacological response test may be available under more than one benefit category [i.e., medical, pharmacy]; therefore, individual benefits must be verified.)
*Erectile Dysfunction: American Urological Association (AUA) Guideline (2018), Varela et al. (2020), Pang et al. (2022), Corona et al. (2017); Slag et al. (1983); Araujo et al. (2007), Bain & Guay (1992); Kwan et al. (1983); Fenwick et al. (1986)​.

NOT MEDICALLY NECESSARY
Penile plethysmography is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the diagnosis of ED. *Murphy et al. (2020); Kedia (1983).

The following diagnostic procedures are considered not medically necessary and, therefore, not covered, because spinal cord injury and other neurological deficits that may cause ED are typically identified during a comprehensive history and examination. These tests do not have any therapeutic implications and are, therefore, unnecessary*:
  • Corpora cavernosal electromyography
  • Dorsal nerve conduction latencies
  • Evoked potential measurements
*Erectile Dysfunction: AUA Guideline (2018); Fanciullacci et al. (1991); Park et al. (2024).

TREATMENT OF ERECTILE DYSFUNCTION

MEDICALLY NECESSARY
The following interventions are considered medically necessary and, therefore, covered for the treatment of ED:
  • Penile prosthetic implants when the following criteria are met:
    • The individual has ED secondary to organic impotence.
    • The individual has no evidence of symptomatic or untreated hypogonadism or hyperprolactinemia and,
    • Other less invasive treatment options, i.e., pharmacological therapy and/or vacuum constriction devices have been tried or considered and ruled out, and the result (if tried) or contraindication (if considered) must be clearly documented in the individual's medical record.
    • The individual receives appropriate preoperative education concerning the benefits and potential risks of the procedure including the possibility of erosion and infection; mechanical failure, and resulting reoperation; and potential reduction of the effectiveness of other therapies if the device is subsequently removed.
*Erectile Dysfunction: AUA Guideline (2018)​

  • Penile revascularization when all of the following criteria are met:
    • The individual has ED that is secondary to a focal arterial occlusion, as evidenced by arteriography or duplex ultrasonography.
      • The individual's arterial occlusion resulted directly from blunt trauma to the pelvis and/or perineum.
    • The individual has no evidence of generalized vascular disease (e.g., diabetes mellitus, hypertension, coronary artery disease), Peyronie's plaques, intracavernosal masses, nodules, or sensory neuropathy.
    • The individual has normal corporeal venous function.
    • Alternative nonsurgical treatment modalities have been fully explained to the individual, and the individual is determined to achieve spontaneous erections without the need for pharmacological, external, or internal support devices.
*Erectile Dysfunction: AUA Guideline (2018); Kawanishi et al. (2004); Trost et al. (2016); Kayigil et al. (2018)

Pharmacological therapy for the treatment of ED may be covered under the prescription plan when the member has a pharmacy benefit.​ Individual benefits must be verified.​​

NOT MEDICALLY NECESSARY 
Penile venous occlusive surgery is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the treatment of erectile dysfunction.*Erectile Dysfunction: AUA Guideline (2018).

NOT COVERED
Vacuum constriction devices are not covered by the Company because they are items not covered by Medicare. Therefore, these devices are not eligible for reimbursement consideration.

EXPERIMENTAL INVESTIGATIONAL
Other treatments for ED including extracorporeal shock wave therapy (ESWT), intracavernosal stem cell therapy, are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.​​*Erectile Dysfunction: AUA Guideline (2018)

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

The evaluation of erectile dysfunction (ED) should begin with a thorough medical history, including, but not limited to, the following:
  • Detailed sexual history
  • Physical examination, including examination of genitals and prostate
  • Assessment of male secondary sexual characteristics
  • Palpation of femoral and lower extremity pulses
  • Focused neurological examination​
The diagnostic evaluation of ED should only include tests that identify the treatment options available to a specific individual and should be based on the individual's clinical status and treatment preferences.

Penile revascularization is usually considered for individuals less than 55 years of age who meet all of the criteria for the procedure as outlined in the Policy section.

Vacuum constriction devices (e.g., Erect Aid) are classified as durable medical equipment (DME).
​
BENEFIT APPLICATION

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

Subject to the terms and conditions of the applicable Evidence of Coverage, the evaluation and treatment of ED is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met. DME used in the treatment of ED may be covered under the medical benefits of the Company’s products when medical necessity criteria in the medical policy are met.

The Company has delegated the responsibility for utilization management activities for professional behavioral health services for ED to the contracted behavioral health vendor.

Description

Erectile dysfunction (ED) is defined as the inability to achieve a sufficient erection for satisfactory sexual performance. Erectile function requires competent arterial blood inflow as well as a reduction of venous blood outflow. Disease and other risk factors may affect the arterial and venous systems in a manner that impedes erectile function and may lead to ED. The causes of ED are divided into the following categories:
  • Psychogenic etiology (originating from the mind or psyche): Caused by factors that include performance anxiety, disaffection with the current sexual partner, lack of sexual arousability, and overt psychiatric disorders such as depression and schizophrenia.
  • Organic etiology, which includes the following causes:
    • Neurogenic: These causes may be central (e.g., spinal cord injury, multiple sclerosis) or peripheral (diabetic polyneuropathy, sacral cord and nerve root compression or trauma)
    • Vasculogenic: Encompasses arterial insufficiency related to arteriosclerosis, tobacco use, or trauma and veno-occlusive efficiency due to trauma, congenital anomalies, and Peyronie disease
    • Myogenic: Conditions such as hypertension, benign prostatic hypertrophy, and radiation injury may cause dysfunction of the intrinsic smooth muscle cells of the erectile tissues
    • Hormonal: Hormones have an influence on both central proerectile pathways and end-organ cavernosal tissues. However, hypogonadism is not considered to be a principal cause of ED in the majority of individuals.
  • Mixed etiology (combination of psychogenic and organic causes). Mixed etiologies for ED are the most common.​
The diagnosis of ED requires a detailed sexual, psychosocial, and medical history, physical examination, and laboratory tests. In addition, diagnostic testing may be needed to support the diagnosis of ED. Examples of this testing include nocturnal penile tumescence testing and pudendal arteriography. Based on a review of available published literature, there is limited support for use of the following tests for the diagnosis of ED:
  • Penile plethysmography
  • Corpora cavernosal electromyography
  • Dorsal nerve conduction latencies
  • Evoked potential measurements
The primary goal of treatment for ED is to restore satisfactory erections with minimal adverse effects. Treatment options for ED include oral medications (phosphodiesterase-5 [PDE5] inhibitors (e.g., sildenafil citrate [Viagra®], vardenafil [Levitra®], tadalafil [Cialis®], avanafil [Stendra®]); intraurethral insertion of prostaglandin E1 (alprostadil); intracavernosal vasoactive drug injection therapy with a combination of papaverine, phentolamine, alprostadil, and atropine [Quad-Mix®] or papaverine, phentolamine, and/or prostaglandin E1 (alprostadil); psychological counseling; vacuum constriction devices (also known as vacuum erection devices); and surgery, including penile revascularization procedures and penile implants. 

As reported by the American Urological Association (AUA), penile venous surgery is not recommended because of the lack of evidence that it constitutes an effective ED management strategy for most individuals. The available data for penile venous occlusive surgery were contributed by observational designs; most studies were retrospective. Limited information was reported regarding individual characteristics such as the presence of comorbidities, particularly those that contribute to vascular integrity. There was considerable variability in participant types, with some individuals diagnosed with one vascular condition (i.e., veno-occlusive dysfunction or arterial disease) and some diagnosed with both conditions. Furthermore, there was considerable variability in surgical technique across studies, making findings interpretation challenging, and follow-up durations were generally short in duration. Finally, most studies did not use validated questionnaires and relied on the individual's reports or medical chart review. Furthermore, this type of procedure has been abandoned in favor of other therapies. 

Among the studies reviewed for treatments for ED, the AUA's Erectile Dysfunction Guideline (2018)​ reported on ​findings from randomized sham-controlled trials that have evaluated low-intensity extracorporeal shockwave therapy (ESWT), which were inconsistent and do not clearly indicate that benefits reliably outweigh risks/burdens for individuals with ED. In particular, the treatment's ability to restore normal erectile function remains in question; the duration of treatment effects beyond possible short-term efficacy is not well established. Consideration is given to the availability of other treatments that are less burdensome and known to be effective. Furthermore, ESWT is not approved by the US Food and Drug Administration to treat ED. Four published systematic reviews with meta-analyses evaluated the use of ESWT. These papers are compromised by the failure to address substantial heterogeneity that suggests flawed conclusions, the pooling of trials across noncomparable patient groups (i.e., ED, chronic pelvic pain; the pooling of trials that measured unassisted erectile function with trials that measured erectile function in response to oral PDE5 inhibitors, and the use of nonstandard data analytic procedures (i.e., separate analyses for active and sham-treated groups). The evidence is insufficient to determine the effects of the technology on health outcomes.​

In addition, the AUA concluded that ​findings from studies that have evaluated intracavernosal stem cell therapy do not indicate that benefits reliably outweigh risks/burdens for individuals with ED. In particular, the treatment's ability to restore normal erectile function in various populations with ED has not been convincingly demonstrated. Moreover, neither the most effective source and dose of stem cells nor the duration of treatment effects has been established. Given the paucity of data obtained in human participants, the risks of treatment also are not well established. Other treatments are well characterized in terms of benefits and risks/burdens are available. The literature consists primarily of observational designs with extremely small sample sizes (<50 individuals in total). The stem cell source and dose varied across studies, making it unclear which protocols might be effective. Individual populations also differed substantially across studies, including individuals with diabetes, individuals who have undergone radical prostatectomy​, and individuals from the general ED population. The safety profile of this therapy is unclear given the limited number of human participants. Overall, confidence in reliable outcomes without significant risks is compromised by an inadequate body of evidence comprising robustly designed studies with sufficient sample sizes for a particular stem cell methodology in a particular group. The evidence is insufficient to determine the effects of the technology on health outcomes.​

CLINICAL BENEFITS OF INTERNALLY DEVELOPED COVERAGE CRITERIA
In accordance with federal regulations, the plan has determined that the use of this additional criterion is necessary to interpret or supplement Medicare's criteria and that it provides clinical benefits that are highly likely to outweigh any clinical harms, including from delayed or decreased access to items or services, because these procedures carry a significant risk of infection, injury, or dysfunction, making it essential to ensure that only carefully selected individuals—those most likely to benefit—are considered appropriate candidates. Contributing factors to erectile dysfunction, such as chronic disease, medication effects, or hormonal imbalances, should be thoroughly evaluated and, when possible, addressed prior to considering these procedures, as doing so may improve outcomes and potentially eliminate the need for more invasive interventions.​

References

Agency for Healthcare Research and Quality (AHRQ). Diagnosis and management of erectile dysfunction. [AHRQ Web site]. 06/09. Available at: https://www.ahrq.gov/downloads/pub/evidence/pdf/erectiledys/erecdys.pdf. Accessed December 16, 2025.

American Association of Clinical Endocrinologists (AACE) Sexual Dysfunction Task Force. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Evaluation and Treatment of Male Sexual Dysfunction: A Couple's Problem. [AACE Web site]. 2003. Available at: https://pro.aace.com/sites/default/files/2019-06/sexdysguid.pdf. Accessed December 16, 2025.

American College of Physicians (ACP). Clinical Practice Guidelines. Hormonal testing and pharmacologic treatment of erectile dysfunction: A clinical practice guideline from the American College of Physicians. [AAFP Web site]. 11/03/2009. Available at:http://www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/acp-hormonaltest-ed.pdf. Accessed December 16, 2025.

American Urological Association (AUA). Guideline for the diagnosis and treatment of erectile dysfunction. 2018. Available at: https://www.auanet.org/guidelines-and-quality/guidelines/erectile-dysfunction-(ed)-guideline. Accessed December 16, 2025​.


Araujo AB, Esche GR, Kupelian V, et al. Prevalence of symptomatic androgen deficiency in men. J Clin Endocrinol Metab. 2007;92(11):4241-4247.


Bacon CG, Mittleman MA, Kawachi I, et al. A prospective study of risk factors for erectile dysfunction. J Urol. 2006;176(1):217-221.


Bain CL, Guay AT. Reproducibility in monitoring nocturnal penile tumescence and rigidity. J Urol. 1992;148(3):811-814. 


Burnett AL, Nehra A, Breau RH, et al. Erectile Dysfunction: AUA Guideline. J Urol. 2018;200(3):633-641.

Canguven O, Bailen J, Fredriksson W, et al. Combination of vacuum erection device and PDE5 inhibitors as salvage therapy in PDE5 inhibitor nonresponders with erectile dysfunction. J Sexual Med. 2009;6(39):2561-2567.

Centers for Medicare & Medicaid Services (CMS). National coverage determination (NCD) for diagnosis and treatment of impotence (230.4). [CMS Web site]. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=32&ncdver=1&bc=AAAAQAAAAAAA&. Accessed December 16, 2025​​.

Chiles KA, Staff I, Johnson-Arbor K, et al.  A double-blind, randomized trial on the efficacy and safety of hyperbaric oxygenation therapy in the preservation of erectile function after radical prostatectomy. J Urol. 2018;199(3):805. 


Corona G, Rastrelli G, Morgentaler A, et al. Meta-analysis of Results of Testosterone Therapy on Sexual Function Based on International Index of Erectile Function Scores. Eur Urol. 2017;72(6):1000-1011. 


Dong L, Chang D, Zhang X, et al. Effect of low-Intensity extracorporeal shock wave on the treatment of erectile dysfunction: A systematic review and meta-analysis. Am J Mens Health. 2019;13(2):1557988319846749.


Fanciullacci F, Colpi GM, Beretta G, Garavaglia PF, Zanollo A. Nerve conduction velocity of dorsal nerve of penis: a modified technique. Urology. 1991;38(6):540-544. 


Fenwick PB, Mercer S, Grant R, et al. Nocturnal penile tumescence and serum testosterone levels. Arch Sex Behav. 1986;15(1):13-21. 

 

Fojecki GL, Tiessen S, Osther PJ. Effect of low-energy linear shockwave therapy on erectile dysfunction-A double-blinded, sham-controlled, randomized clinical trial. J Sex Med. 2017;14(1):106. 

 

Hadanny A, Lang E, Copel L, et al. Hyperbaric oxygen can induce angiogenesis and recover erectile function. Int J Impot Res. 2018;30(6):292. 

Kawanishi Y, Kimura K, Nakanishi R, et al. Penile revascularization surgery for arteriogenic erectile dysfunction: the long-tern efficacy rate calculated by survival analysis. BJU Int. 2004;94(3):361-368.


Kayigil O, Okulu E, Akdemir F, Cakici OU. The combination of penile revascularization surgery with penile corrective techniques as an alternative to prosthesis implantation in patients with peyronie's disease accompanied by erectile dysfunction: Long-term results. Int J Impot Res. 2018;30(2):71-78. 


Kedia KR. Penile plethysmography useful in diagnosis of vasculogenic impotence. Urology. 1983;22(3):235-239. 

 

Khera M, Albersen M, Mulhall JP. Mesenchymal stem cell therapy for the treatment of erectile dysfunction. J Sex Med. 2015;12(5):1105. 

 

Khera M. Treatment of male sexual dysfunction. UpToDate. [UpToDate Web site]. 10/04/23. Available at: http://www.uptodate.com [via subscription only]. Accessed December 16, 2025​​.


Kwan M, Greenleaf WJ, Mann J, et al. The nature of androgen action on male sexuality: a combined laboratory-self-report study on hypogonadal men. J Clin Endocrinol Metab. 1983;57(3):557-562. ​


Mayo Clinic. Penile Implants. [Mayo Clinic Web site]. Available at: https://www.mayoclinic.org/tests-procedures/penile-implants/about/pac-20384916. Accessed December 16, 2025.

Müller A, Mulhall JP. Cardiovascular disease, metabolic syndrome and erectile dysfunction. Curr Opin Urol. 2006;16(6):435-443.


Murphy L, Gottfried E, DiMario K, et al. Use of penile plethysmography in the court: A review of practices in Canada, the United Kingdom and the United States. Behav Sci Law. 2020;38(2):79-99.


National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC). Erectile dysfunction. [NKUDIC Web site]. June 2009. Available at: https://www.niddk.nih.gov/health-information/urologic-diseases/erectile-dysfunction. Accessed December 16, 2025​.

Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD).L34824: Vacuum Erection Devices (VED). [Noridian Healthcare Solutions Web site]. Original: 10/01/15. (Revised: 01/01/2020). Available at: https://med.noridianmedicare.com/web/jadme/policies/lcd/active. Accessed December 16, 2025​.


Noridian Healthcare Solutions, LLC. RETIRED - Vacuum Erection Devices - Non-Covered by Medicare. [Noridian Healthcare Solutions Web site]. 07/01/2015. Available at: https://med.noridianmedicare.com/web/jddme/policies/dmd-articles/veds-non-covered-by-medicare. Accessed December 16, 2025​.


Pang K, Pan D, Xu H, et al. Advances in physical diagnosis and treatment of male erectile dysfunction. Front Physiol. 2023;13:1096741. 


Park E, Chang SY, Park HJ, Namgung HG, Won SJ. Dorsal ulnar cutaneous nerve conduction study based on nerve ultrasound. Sci Rep. 2024;14(1):20422. ​​


Qaseem A, Snow V, Denberg TD, et al. Hormonal testing and pharmacologic treatment of erectile dysfunction: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2009;151(9):1-11.

Reproductive and sexual function. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA. Campbell-Walsh Urology. 9th edition. Philadelphia, PA: WB Saunders; 2007.


Rosen R, O'Leary M. Epidemiology and etiologies of male sexual dysfunction. UpToDate. [UpToDate Web site]. 10/31/2024. Available at: http://www.uptodate.com [via subscription only]. Accessed December 16, 2025.​

 

Sahin MO, Sen V, Eser E, et al. The effect of hyperbaric oxygen therapy on erectile functions: A prospective clinical study. Urol Int. 2018;101(2):206-211.
​
Shabsigh R, Stone B. Understanding the needs and objectives of erectile dysfunction patients. World J Urol. 2006;24(6):618-622.


Slag MF, Morley JE, Elson MK, et al. Impotence in medical clinic outpatients. JAMA. 1983;249(13):1736-1740.


Trost LW, Munarriz R, Wang R, Morey A, Levine L. External Mechanical Devices and Vascular Surgery for Erectile Dysfunction. J Sex Med. 2016;13(11):1579-1617.


Varela CG, Yeguas LAM, Rodríguez IC, Vila MDD. Penile Doppler Ultrasound for Erectile Dysfunction: Technique and Interpretation. AJR Am J Roentgenol. 2020;214(5):1112-1121.

Coding

CPT Procedure Code Number(s)
MEDICALLY NECESSARY

THE FOLLOWING CODES ARE MEDICALLY NECESSARY FOR THE EVALUATION AND TREATMENT OF ERECTILE DYSFUNCTION:

36245, 36246, 36247, 36248, 37788, 54115, 54230, 54231, 54235, 54250, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, 54437, 54438, 74445, 75736, 93975, 93976, 93978, 93979, 93980, 93981

NOT MEDICALLY NECESSARY

THE FOLLOWING CODES ARE NOT MEDICALLY NECESSARY FOR THE EVALUATION AND TREATMENT OF ERECTILE DYSFUNCTION:

 37790, 51792, 54240, 95870, 95907, 95908, 95909, 95910, 95911, 95912, 95913

EXPERIMENTAL/INVESTIGATIONAL

0864T

ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)

F52.21 Male erectile 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

N52.33 Erectile dysfunction following urethral surgery

N52.34 Erectile dysfunction following simple prostatectomy

N52.35 Erectile dysfunction following radiation therapy

N52.36 Erectile dysfunction following interstitial seed therapy

N52.37 Erectile dysfunction following prostate ablative therapy

N52.39 Other and unspecified postprocedural erectile dysfunction

N52.8 Other male erectile dysfunction

N52.9 Male erectile dysfunction, unspecified

HCPCS Level II Code Number(s)

MEDICALLY NECESSARY
 

THE FOLLOWING CODES ARE MEDICALLY NECESSARY FOR THE TREATMENT OF ERECTILE DYSFUNCTION:

C1813 Prosthesis, penile, inflatable

C2622 Prosthesis, penile, noninflatable​


NOT COVERED


THE FOLLOWING CODES ARE NOT COVERED FOR THE TREATMENT OF ERECTILE DYSFUNCTION:

L7900 Male vacuum erection system

L7902 Tension ring, for vacuum erection device, any type, replacement only, each

Revenue Code Number(s)
N/A



Coding and Billing Requirements

Policy History

Revisions From MA11.079e:

​01/21/2026
​The policy has been reviewed and reissued to communicate the Company’s continuing position on evaluation and treatment of erectile d​Misspelled Wordysfunction (ED)​.
​07/09/2025​This policy has been reissued in accordance with the Company's annual review process.​
05/29/2024

​This policy has been reissued in accordance with the Company's annual review process​.
01/02/2024This policy has been identified for a CPT code update, effective 01/02/2024.

The following CPT code has been added to this policy: 0864T
​01/01/2024

​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.


Revisions From MA11.079d:
​05/31/2023

​This policy has been reissued in accordance with the Company's annual review process​.
06/15/2022This policy has been reissued in accordance with the Company's annual review process.
​09/13/2021

​This version of the policy will become effective 09/13/2021. 
The policy has been updated to address ​Experimental/Investigational treatments for erectile dysfunction.

The following HCPCS codes have been added to this policy:
C1813 Prosthesis, penile, inflatable
C2622 Prosthesis, penile, Misspelled Wordnoninflatable

Revisions From MA11.079c:
03/25/2020This policy has been reissued in accordance with the Company's annual review process.
04/24/2019This policy has been reissued in accordance with the Company's annual review process.
06/20/2018Effective 6/20/18, this policy has been reviewed and reissued to communicate the Company’s continuing position on the Evaluation and Treatment of Erectile Dysfunction (ED).
09/13/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on the Evaluation and Treatment of Erectile Dysfunction (ED).
10/01/2016The following ICD-10 Diagnosis codes have been added to this policy: N52.35, N52.36, N52.37

The following ICD-10 Diagnosis narrative has been revised in this policy: N52.39

Revisions From MA11.079b:
04/27/2016This policy has been reviewed and reissued to communicate the Company’s continuing position on the Evaluation and Treatment of Erectile Dysfunction (ED).
01/01/2016This version of the policy will become effective 01/01/2016. The following CPT codes: 54437 & 54438 have been added to the policy.

Revisions From MA11.079a:
08/12/2015Revised policy number MA11.079a was issued as a result of annual policy review. This version of the policy will become effective 08/12/2015.

The following changes have been made to the policy:
  • In accordance with recently released CMS guidelines, vacuum erection devices will no longer be covered for Medicare Advantage members effective 07/01/2015.
  • Medical necessity criteria for penile prosthetic implants have been added to the policy.

Revisions From MA11.079:
01/01/2015This is a new policy.

1/2/2024
1/2/2024
1/21/2026
MA11.079
Medical Policy Bulletin
Medicare Advantage
No
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.