Clinical UM Guideline
|Subject:||Penile Prosthesis Implantation|
|Guideline #:||CG-SURG-12||Current Effective Date:||08/10/2015|
|Status:||Revised||Last Review Date:||08/06/2015|
This document addresses the criteria for implantation of a penile prosthesis, which is an established technique for treating male impotence or erectile dysfunction (ED) due to neurogenic or vasculogenic causes.
The implantation of a penile prosthesis is considered medically necessary for individuals who have NOT responded to intracavernosal injection, intra-urethral medications, a vacuum constriction device and oral medications, or such treatment is not acceptable to the individual or his partner AND who meet one of the following criteria:
Not Medically Necessary:
The implantation of a penile prosthesis is considered not medically necessary when the above criteria are not met.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|54400||Insertion of penile prosthesis; non-inflatable (semi-rigid)|
|54401||Insertion of penile prosthesis; inflatable (self-contained)|
|54405||Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir|
|54410||Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session|
|54411||Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue|
|54416||Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session|
|54417||Removal and replacement of a non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue|
|C1813||Prosthesis, penile, inflatable|
|C2622||Prosthesis, penile, non-inflatable|
|L8699||Prosthetic implant, not otherwise specified|
|ICD-10 Procedure||[For dates of service on or after 10/01/2015]|
|0VUS0JZ||Supplement penis with synthetic substitute, open approach|
|0VUS4JZ||Supplement penis with synthetic substitute, percutaneous endoscopic approach|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
|ICD-9 Procedure||[For dates of service prior to 10/01/2015]|
|64.95||Insertion or replacement of non-inflatable penile prosthesis|
|64.97||Insertion or replacement of inflatable penile prosthesis|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
The American Urological Association (AUA) Guideline on the Management of Erectile Dysfunction: Diagnosis and Treatment Recommendations defines the index case of ED as the absence of hypogonadism or hyperprolactinemia in a man who develops, after a well-established period of normal erectile function, ED that is primarily organic in nature (AUA, 2005, Update 2007). The European Association of Urology (EAU) defines ED as the "Persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance" (Hatzimouratidis, 2015).
The AUA (2007) guidelines note "Cardiovascular disease and ED may share a common etiology when endothelial dysfunction and atherosclerosis affect both coronary arteries and penile vasculature." The EAU guideline notes "ED shares both unmodifiable and modifiable common risk factors with CVD (e.g., obesity, diabetes mellitus, dyslipidemia, metabolic syndrome, lack of exercise, and smoking)" (Hatzimouratidis, 2015). The Princeton guideline for sexual medicine addressed sexual dysfunction and cardiac risk and was updated in 2006 with the publication of the second consensus statement. The guideline noted individuals with no known cardiovascular disease but presenting with ED may have other comorbidities (e.g., diabetes, hypertension, hyperlipidemia, heart disease) (Jackson, 2006).
The AUA (2007) guideline update for erectile dysfunction states:
The management of erectile dysfunction begins with the identification of organic comorbidities and psychosexual dysfunctions; both should be appropriately treated or their care triaged. The currently available therapies that should be considered for the treatment of erectile dysfunction include the following: oral phosphodiesterase type 5 [PDE5] inhibitors, intra-urethral alprostadil, intracavernous vasoactive drug injection, vacuum constriction devices, and penile prosthesis implantation. These appropriate treatment options should be applied in a stepwise fashion with increasing invasiveness and risk balanced against the likelihood of efficacy.
The EAU guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation (Hatzimouratidis, 2015) recommend the implanted penile prosthesis as a third line of therapy for individuals that have failed other non-surgical treatments.
Damage to nerves, arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of ED. Vascular disease and neurologic disease account for about 70% of ED cases. Between 35 and 50 percent of men with diabetes experience ED. Surgery (especially radical prostate and bladder surgery for cancer) and radiotherapy can injure nerves and arteries near the penis, causing ED (AUA, 2007; Chung, 2014; NCCN, 2015). Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to ED by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa.
Use of a penile prosthesis is an established technique for treating male impotence due to neurogenic or vasculogenic disease processes after failure of less invasive medical treatments (AUA, 2007; Chung, 2014; Hatzimouratidis, 2015). Penile implants involve surgical insertion of malleable or inflatable rods or tubes into the penis. The surgery is not without possible complications. Minervini and colleagues (2006) studied 447 men who had 504 penile prosthetics implanted and found that infection was the most frequent complication. Other complications were implant migration and tissue erosion. In a review by Phe (2012), the rate of infection had decreased to 1% with the utilization of antibiotic impregnated implants.
Zermann and colleagues (2006) studied 245 neurologically impaired men who had penile prosthetics implanted. There were 3 groups based on the indication for penile prosthetic surgery. Group 1 consisted of 134 participants with urinary management only, Group 2 had 60 participants with erectile dysfunction only, and Group 3 had 51 participants with urinary management and erectile dysfunction. At a mean follow-up of 7.2 years (maximum 17 years), 195 participants were reevaluated in the clinic. Outcomes showed that in 122 participants (90.3%) urinary management problems were resolved, and erectile dysfunction treatment was successful in 76 participants (82.6%). Forty-three revisions were performed for complications (e.g., infections and device perforation).
The U.S. Food and Drug Administration (FDA) considers the rigid penile implant as a Class II device. The semi-rigid rods are implanted into the corpora cavernosa of the penis to provide rigidity. Inflatable penile implants are considered Class III devices by the FDA. Inflatable cylinders are implanted in the penis and are connected to a reservoir filled with fluid implanted in the abdomen, and a subcutaneous manual pump implanted in the scrotum. Penile rigidity is achieved when the cylinders are filled with fluid.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Penile Prosthesis, Insertion
|Revised||08/06/2015||Medical Policy & Technology Assessment Committee (MPTAC) review. Reformatted and reorganized criteria. Added medically necessary criteria for radiation therapy. Added pelvis and retroperitoneum to major surgery group. Updated Description, Discussion/General Background, and References sections.|
|Reviewed||11/13/2014||MPTAC review. Updated Description, Discussion/General Background, and References sections.|
|Reviewed||11/14/2013||MPTAC review. Updated Discussion/General Background, References and Websites sections.|
|Reviewed||11/08/2012||MPTAC review. Discussion and References updated.|
|Reviewed||11/17/2011||MPTAC review. Discussion, Coding and References updated.|
|Reviewed||11/18/2010||MPTAC review. Discussion and References updated.|
|Reviewed||11/19/2009||MPTAC review. Place of Service section deleted. Discussion and References updated.|
|Reviewed||11/20/2008||MPTAC review. References updated.|
|Reviewed||11/29/2007||MPTAC review. References and coding were updated.|
|Reviewed||12/07/2006||MPTAC review. References updated; no change to guideline criteria.|
|Revised||12/01/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Pre-Merger Organizations||Last Review Date||Document Number||Title|
|Anthem, Inc.||No Document|
|Anthem BCBS||No Document|
|WellPoint Health Networks, Inc.||12/02/2004||Clinical Guideline||Penile Prosthesis Insertion|