Mountain State Medical Policy Bulletin
Section: Miscellaneous
Number: G-9
Topic: Treatment of Male Sexual Dysfunction
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

Treatment of sexual dysfunction is eligible for payment only when the condition is the result of or related to an organic disease or injury. In these instances, covered services include, but are not limited to:


  • Nocturnal penile tumescence recordings (54250)
  • Insertion and removal of penile prosthesis (54400-54417)

When a contract benefit, hormone injections (e.g., testosterone) the Snap-Gauge device (A4649) and vacuum constriction devices (e.g., ErecAid) (code L7900) are covered.

Follow-up surgery to the insertion of a prosthesis because of infection and/or malfunction of the device should be paid under the appropriate procedure code.

Venous ligation is performed as treatment for patients with failure to store blood in the cavernosa. Venous ligation is not an eligible service on the basis of medical necessity.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

542505440054401544055440654408
5441054411544155441654417A4649
L7900     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Services and supplies (including drugs and devices) related to the treatment of sexual dysfunction or inadequacies are not covered regardless of whether the cause of the impotency is organic or psychological/psychiatric. However, services such as the initial diagnostic testing that may be required to determine if the sexual dysfunction or inadequacy is due to an organic or pathological problem (e.g., nocturnal penile tumescence testing) are eligible.

Also refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.