DESCRIPTION
Dynamic infusion cavernosometry and cavernosography (DICC) is a procedure that involves four phases to evaluate the flow of blood and pressure functions of the penis. The test assesses the integrity of the arterial and venous circulatory systems of the penis during an erection. DICC is invasive, requiring two needles to remain in the penis for saline infusion and pressure recording. Local anesthesia and an intracavernosal injection of a vasoactive drug are given prior to initiation. This procedure has primarily been reserved for individuals considering the option of vein ligation with or without arterial bypass.
POLICY
Dynamic infusion cavernosometry and cavernosography for the diagnosis of erectile dysfunction is considered not medically necessary.
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
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.
BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2002). Erectile Dysfunction (2.01.25). Retrieved October 12, 2007 from BlueWeb.
Broderick, G. A. (1998). Evidence based assessment of erectile dysfunction. International Journal of Impotence Research, 10 (2), S64-S73.
Kayigil, O., Atahan, O., Metin, A. (1995). Dynamic infusion cavernosometry and cavernosography in diagnosing and classifying veno-occlusive dysfunction. International Urology and Nephrology, 27(5), 615-620.
National Institutes of Health. (1992, December). Impotence. NIH consensus statement. Retrieved August 6, 2001. Available at: http://odp.od.nih.gov/consensus/cons/091/091_statement.htm.
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.
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