DESCRIPTION
The mechanism of external penile vacuum constriction devices serves to draw blood into the penis to create an artificial erection. Vacuum constriction devices consist of a hollow plastic cylinder, a vacuum pump, a connector tube between the cylinder and the pump, and an elastic constriction band. After the attachment of the cylinder, a vacuum draws blood into the penis and the blood is held in place temporarily by a constricting band. The use of these devices does not require surgery.
POLICY
External penile vacuum constriction devices for the treatment of erectile dysfunction are considered medically necessary.
External penile vacuum constriction devices for the treatment of psychogenic erectile dysfunction are 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
External penile vacuum constriction devices for the treatment of erectile dysfunction should be used with caution for the following individuals:
On anticoagulants
Who have a history of blood dyscrasias
The following is a listing of some External Vacuum Devices that are available:
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SOURCES
Agency for Health Care Policy and Research. (1990). Diagnosis and treatment of impotence. Retrieved November 8, 2007 from http://www.ahrq.gov/clinic.impot2.htm. (170 articles and/or guidelines reviewed)
BlueCross BlueShield Association, Medical Policy Reference Manual. (4:2002). Erectile Dysfunction (2.01.25). Retrieved November 8, 2007 from BlueWeb.
National Guideline Clearinghouse. (2006). The management of erectile dysfunction: an update. Retrieved November 8, 2007 from http://www.guideline.gov/summary/summary.aspx?doc_id=10018&nbr=005332&string=external+AND+penile+AND+vacuum+AND+devices. (78 articles and/or guidelines reviewed)
National Institutes of Health. (1992, December). Consensus Statements. Impotence (Vol. 10, No. 4). Retrieved November 8, 2007 from http://consensus.nih.gov/1992Impotence091html.htm.
U. S. Food and Drug Administration. (2004, December). Center for Devices and Radiological Health. Class II special controls guidance document: External penile rigidity devices. Retrieved November 8, 2007 from http://www.fda.gov/cdrh/ode/guidance/1231.pdf.
ORIGINAL EFFECTIVE DATE: 4/27/1998
MOST RECENT REVIEW DATE: 5/1/2008
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.