DESCRIPTION
Penile revascularization is the correction of erectile dysfunction using surgical or microsurgical procedures to bypass arterial occlusions or repair venous insufficiencies. Penile revascularization is a complicated surgical procedure in which major arteries are accessed to restore penile blood flow. Arterial bypass procedures circumvent the area where critical arteries are obstructed or too narrow to permit adequate blood flow to the penis. Venous revascularization techniques repair the venous leaks occurring in the corpus cavernosum.
Revascularization techniques that create a bypass of the distal arterial occlusion and provide a new arterial blood flow into the corpus cavernosum include:
Michal II
Hauri Technique
Crespo Technique
Revascularization techniques that supply the corpus cavernosum through the collateral deep dorsal venous network or through a surgical fistula between the arterialized vein and the corpus cavernosum include:
Viraq-5
Modified Viraq-5
POLICY
Penile revascularization, including arterial bypass and venous repair, for the treatment of erectile dysfunction is considered investigational.
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
Policies with similar titles: Erectile Dysfunction - Penile Venous Occlusive Procedure
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
Scientific evidence in the form of published articles in peer-reviewed journals are lacking regarding long-term outcomes and long-term adverse events.
SOURCES
American Urological Association. (2007). Erectile dysfunction. The management of erectile dysfunction: An update. Retrieved November 12, 2007 from http://www.auanet.org/guidelines/main_reports/edmgmt/chapter1.pdf.
Bertolotto, M., Calderan, L., & Cova, M. A. (2005). Imaging of penile traumas - therapeutic implications. European Radiology, 15 (12), 2475-2482. Abstract retrieved November 13, 2007 from PubMed database.
BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2002). Erectile Dysfunction (2.01.25). Retrieved November 12, 2007 from BlueWeb. (1 articles and/or guidelines reviewed)
Complete Guide to Medicare Coverage Issues [Computer software]. (2007, July). Diagnosis and treatment of impotence (NCD 230.4, p. 2-183). St. Anthony Publishing.
Coughlin, L. (2006). Practice guidelines. AUA updates guidelines on management of erectile dysfunction. American Family Physician, 73 (2), 342-346.
Hayes. Medical Technology Directory. (1996, October). Penile revascularization. Retrieved March 23, 2003 from www.Hayesinc.com/subscribers. (21 articles and/or guidelines reviewed)
Kawanishi, Y., Kimura K., Nakanishi, R., Kojima, K., & Numata, A. (2004). Penile revascularization surgery for arteriogenic erectile dysfunction: The long-term efficacy rate calculated by survival analysis. British Journal of Urology International, 94 (3), 361-368.
Kawanishi, Y., Kimura K., Nakanishi, R., Fukawa, T., & Numata, A. (2004). A minimally invasive method for harvesting the epigastric artery for penile revascularization. British Journal of Urology International, 94 (9), 1391-1396.
National Guideline Clearinghouse. (2006, May). The management of erectile dysfunction: An update. Retrieved November 13, 2007 from http://www.guidelines.gov.
Vardi, Y., Gruenwald, I., Gedalia, U., Nassar, S., Engel A., & Har-Shai, Y. (2004). Evaluation of penile revascularization for erectile dysfunction: A 10-year follow-up. International Journal of Impotence Research, 16 (2), 181-186. Abstract retrieved November 13, 2007 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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