DESCRIPTION
The penile brachial index (PBI) is calculated by comparing the penile systolic blood pressure (B/P), determined by a doppler, with the brachial systolic B/P at rest and after exercise. The normal range for PBI is equal to or more than 0.75, while abnormal range for PBI is equal to or less than 0.6. A PBI that is not within the normal range indicates a vascular etiology. An intracavernosal injection of a vasoactive drug may be administered prior to the test.
POLICY
Penile brachial index testing for the diagnosis of erectile dysfunction is considered medically necessary.
Penile brachial index duplicate testing 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.
ADDITIONAL INFORMATION
PBI testing is performed in conjunction with penile plethysmography.
The following vasoactive drugs may be used prior to PBI testing:
Papaverine Hydrochloride
Phentolamine Mesylate
Prostaglandin E1
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2002). Erectile dysfunction (2.01.25). Retrieved November 8, 2007 from BlueWeb.
Broderick, G. A. (1998). Evidence based assessment of erectile dysfunction. International Journal of Impotence Research, 10 (2), S64-S73. Abstract retrieved August 17, 2001 from PubMed database.
Chiu, R. C., Lidstone, D., Blundell, P. E. (1986). Predictive power of penile/brachial index in diagnosing male sexual impotence. Journal Vascular Surgery, 4 (3), 251-256. Abstract retrieved January 25, 2000 from PubMed database.
DePalma, R. G., Olding, M., Yu, G. W., Schwab, F., J., Druy, E. M., Miller, H. C., et al. Vascular interventions for impotence: lessons learned. (1995). Journal of Vascular Surgery, 21 (4), 576-584. Abstract retrieved January 25, 2000 from PubMed database.
Dow, J. A., Gluck, R. W., Golimbu, M., Weinbert, G. I., Morales, P. (1991). Multiphasic diagnostic evaluation of arteriogenic, venogenic, and sinusoidogenic impotency. Value of noninvasive tests compared with penile duplex ultrasonography. Urology, 38 (5), 402-407. Abstract retrieved January 25, 2000 from PubMed database.
Purvis, K., Brekke, I., Christiansen, E. Determinants of satisfactory rigidity after intracavernosal injection with prostaglandin E1 in men with erectile failure. (1996). International Journal of Impotence Research, 8 (1), 9-16. Abstract retrieved January 25, 2000 from PubMed database.
Takasaki, N., Kotani, T., Miyazaki, S., Saitou, S. (1989). Measurement of penile brachial index (PBI) in patients with impotence. Hinyokika Kiyo, 35 (8), 1365-1368. Abstract retrieved January 25, 2000 from PubMed database.
ORIGINAL EFFECTIVE DATE: 4/27/1998
MOST RECENT REVIEW DATE: 12/13/2007
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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