DESCRIPTION
Nocturnal penile tumescence (NPT) testing is a portable, non-invasive, technique that electronically monitors the frequency, rigidity, and/or circumferential changes of erections during REM sleep. An absence of erections indicates a probable organic etiology.
The RigiScan test measures both penile tumescence and rigidity on a continuous basis. The device consists of two loops surrounding the penis that are attached to a small computer with memory capacity.
The strain-gauge test measures changes in penile circumference. An elastic loop containing a conductive material such as mercury is placed around the shaft of the penis. An increase in circumference causes a stretching of the loop and a change in electrical signal, which is recorded on the monitor.
POLICY
Nocturnal penile tumescence testing for the diagnosis of erectile dysfunction is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Duplicate testing is considered not medically necessary.
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
MEDICAL APPROPRIATENESS
Nocturnal penile tumescence testing for the diagnosis of erectile dysfunction is considered medically appropriate if ANY ONE of the following criteria are met:
The individual reports a complete absence of erections (exclusive of nocturnal sleep erections)
Erectile dysfunction is suspected to be primarily psychogenic in origin
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.
ADDITIONAL INFORMATION
The following NPT tests are less expensive and are reserved exclusively for in home use. Their use will be considered part of the patient office evaluation:
The postage stamp test uses adhesive paper stamps (1 1/4" x 1") similar to postage stamps. Four stamps are snugly wrapped around the penis with the overlying stamp wetted and sealed. The following morning, the stamps are examined for breaks along the perforations. This may be repeated for a three-night period.
The snap-gauge test measures penile rigidity. Three plastic elements are arranged in parallel on a Velcro fastener that is wrapped around the penis; each plastic film breaks at a determined rigidity measure (e.g., 10, 15, or 20 ounces).
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (2002, April). Erectile Dysfunction (2.01.25). Retrieved October 30, 2008 from BlueWeb.
Broderick, G. A. (1998). Evidence based assessment of erectile dysfunction. International Journal of Impotence Research. 10 Suppl 2, S64-73.
McMahon, C. G. & Touma, K. (1999). Predictive value of patient history and correlation of nocturnal penile tumescence, colour duplex Doppler ultrasonography and dynamic cavernosometry and cavernosography in the evaluation of -erectile dysfunction. International Journal of Impotence Research, 11 (1), 47-51. Abstract retrieved December 3, 2003 from PubMed database.
ORIGINAL EFFECTIVE DATE: 4/27/1998
MOST RECENT REVIEW DATE: 1/8/2009
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.