DESCRIPTION
The biothesiometer uses a fixed frequency variable amplitude vibration to measure the sensory perception threshold of the penis. The test evaluates the afferent somatic dorsal pathway.
POLICY
Biothesiometry for the neurological evaluation of erectile dysfunction is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
See also: Nocturnal Penile Tumescence (NPT) Testing
MEDICAL APPROPRIATENESS
Biothesiometry is considered medically appropriate as part of the evaluation and management during an office visit examination when if any of the following criteria are met:
Nocturnal penile tumescence testing suggests sensory neuropathy due to organic impotence; or
History indicates sensory neuropathy; or
Complaint of retarded ejaculation.
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
SOURCES
Agency for Health Care Research and Quality. (1990). Diagnosis and treatment of impotence. Retrieved August 2, 2001 from http://www.ahcpr.gov/clinic/impot2.htm.
American Urological Association. (2007, June). Clinical Guidelines. The management of erectile dysfunction: An update. Retrieved October 12, 2007 from http://www.auanet.org/guidelines/edmgmt.cfm.
Bemelmanis, B. L., Hendrikx, L. B., Koldewijin, E. L., Lemmens, W. A., Debruyne, F. M., & Meuleman, E. J. (1995). Comparison of biothesiometry and neuro-urophysiological investigations for the clinical evaluation of patients with erectile dysfunction. Journal of Urology, 153 (5), 1483-1486. Abstract retrieved July 24, 1997 from PubMed database.
BlueCross BlueShield Association. Medical Policy Manual. (4:2002). Erectile dysfunction (2.01.25). Retrieved October 12, 2007 from BlueWeb.
BlueCross BlueShield of Tennessee network physicians. December 1997.
Chun, J., Carson, C. C. (2001). Erectile dysfunction: physician-patient dialogue and clinical evaluation of erectile dysfunction. Urologic Clinics of North America, 28 (2), 349-358.
Complete Guide To Medicare Coverage Issues [Computer software]. (2007, July). Diagnosis and treatment of impotence. (NCD 230.4, p. 2-183). St. Anthony Publishing.
Kadioglu, A., Memisoglu, K., Sazova, O., Erdogru, T., Karsidag, K., & Tellaloglu, S. (1994). The effects of diabetes on penile somato-afferent system. Archivos Espanoles de Urologia, 47 (1), 100-103. Abstract retrieved July 24, 1997 from PubMed database.
Lue, T. E. (2002). Evaluation of the complex patient, additional testing, and when to refer. In P. C. Walsh (Ed.). Campbell's Urology (8th ed., p. 1638). St. Louis: W. B. Saunders Company.
National Institutes of Health. (1992, December). Impotence: NIH Consensus Statement, 10, (4), 1-31.Retrieved March 10, 2003 from http://consensus.nih.gov/1992/1992Impotence091PDF.pdf.
ORIGINAL EFFECTIVE DATE: 4/27/1998
MOST RECENT REVIEW DATE: 11/8/2007
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.