DESCRIPTION
Internal penile prosthetic devices are surgically implanted into the penis to create an artificial erection. The procedure may be done in the hospital, or in some cases in the outpatient setting. There are two types of devices:
Inflatable - of which three types exist:
Three-component device: consists of two cylinders placed in the corpora cavernosa, a pump in the scrotum, and a fluid reservoir in the space before the urinary bladder.
Two-component device: consists of two cylinders and a reservoir pump combination in the scrotum.
Single-component, self-contained cylindrical unit: each cylinder contains an inflatable chamber, a proximal fluid reservoir, and fluid pump with a deflation mechanism.
Non-inflatable - consists of a silicone rod with a central core of stainless steel wires or articulating plastic segments.
Most of these devices do not allow the penis to return to a flaccid state.
POLICY
The use of an internal penile prosthesis for the treatment of erectile dysfunction is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
The use of an internal penile prosthesis for the treatment of psychogenic erectile dysfunction is considered not medically necessary.
MEDICAL APPROPRIATENESS
The use of an internal penile prosthesis is considered medically appropriate in individuals 18 years of age or older if any of the following criteria are met:
Paraplegia or quadriplegia; or
Pelvic trauma with urinary system injury; or
Peyronie's disease; or
History of radiation therapy to the pelvis; or
History of radical pelvic or perineal surgery (such as cystectomy, prostatectomy, partial penectomy, abdominal perineal resection, anterior exenteration, or total pelvic exenteration); or
For other organic diagnoses, documentation must indicate all other forms of therapy have failed; or
Absence of severe penile corporal fibrosis; or
Severe medical illnesses do not exist.
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 Urology Association. (2007, June). The management of erectile dysfunction: An update. Retrieved October 30, 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 30, 2007 from BlueWeb.
Complete Guide to Medicare Coverage Issues [Computer software]. (2007, July). Diagnosis and treatment of impotence (NDC 230.4, p. 2-183). St. Anthony Publishing.
Greiner, K. A., & Weigel, J. W. (1996). Erectile dysfunction. American Family Physician, 54 (5), 1675-1682.
National Institutes of Health. (1992, December). Consensus Development Conference Statement: Impotence. Retrieved August 17, 2001 from http://consensus.nih.gov/1992/1992Impotence091PDF.pdf.
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.
This document has been classified as public information.