Archived Policies - Surgery


Evaluation of Impotence

Number:SUR717.006

Effective Date:09-01-1999

End Date:02-14-2007

Coverage:

Evaluation of Impotence MAY BE ELIGIBLE FOR COVERAGE for the following diagnostic studies after a complete history and physical (medical and sexual) has been completed. These diagnostic studies include, but are not limited to, the following:

  • Laboratory Studies:
    1. Hormonal Evaluation (includes testosterone, luteinizing hormone, follicle stimulating hormone, prolactin levels), and
    2. Diabetes Screening (includes glucose tolerance testing);
  • Morning Sleep Nap
  • Pharmacologic Screening Test, Intracavernosal Injection of Papaverine, Phentolamine, or Prostaglandin E[sub 1] (PGE1);
  • Evaluation of Penile Arterial Flow:
    1. Penile Brachial Index using a doppler signal transducer,
    2. Pudendal Arteriography with Intracavernosal Injection (ICI) using vasodilating agents,
    3. Angiography (with ICI) using vasodilating agents;
    4. Duplex Doppler Sonography or Color Doppler Sonography (with ICI) using vasodilating agents;
  • Veno-Occlusive Dysfunction Testing:
    1. Cavernosography utilizing a radiocontrast solution (with ICI) using vasodilating agents,
    2. Cavernosometry with simultaneous infusion of saline solution (with or without ICI) using vasodilating agents.

Penile Plethysmography IS NOT ELIGIBLE FOR COVERAGE as this diagnostic testing has been replaced by newer, more accurate assessments and measurements of penile blood flow.

Corpus Cavernosum Electromyography (CCEMG) and Single Potential Analysis of Cavernous Electrical Activity (SPACE) ARE NOT ELIGIBLE FOR COVERAGE as part of an evaluation of impotence as these diagnostic evaluations are considered investigational.

Description:

Evaluation of Impotence begins with a comprehensive history and physical examination.  A careful sexual history and knowledge of concurrent illnesses and medications are essential.  In addition, a clinical evaluation may include the following:

  • Laboratory Studies including Hormonal Assessment and/or Diabetes Screening,
  • Morning Sleep Nap/Nocturnal Penile Tumescence Testing,
  • Pharmacologic Screening Testing including administering vascular dilating agents testing the penile erection process,
  • Evaluation of Penile Arterial Flow including Doppler Studies, Angiography or Arteriography,
  • Veno-Occlusive Dysfunction Testing to include Cavernosography and Cavernosometry.

Rationale:

Considerable attention has been paid to the evaluation and treatment of sexual dysfunction due to the development of new drugs and procedures.

Erectile dysfunction or impotence can be a secondary symptom of systemic diseases or their treatment, such as diabetes mellitus, hypertension, blood lipid abnormalities, or peripheral vascular disease.  Evaluation of impotence should include detailed medical and sexual history, physical examination, and basic lab studies.  Further diagnostic studies may be required to assess:

  • Erectile responses to medications,
  • Abnormalities in vascular flow, and/or
  • Absence of erections during sleep.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

None


Medicare Coverage:

None

References:

Berkow, Robert M.D., and Andrew J. Fletcher, M.B., B.Chir., eds. 1992. The Merck Manual, 17th edition. New Jersey: Merck & C., Inc.: 1575-6.

NIH Consensus Conference. "Impotence. NIH Consensus Development Panel on Impotence." (1993 July 7) 270(1): 83-90.

"The Testis." 1995 Scientific American Medicine (CD Rom/on-line) Chapter II (1995 January): 1-22.

DeWire, D.M. "Evaluation and treatment of erectile dysfunction." American Family Physician (1996 May 1) 53(6): 2101-8.

Connolly, J.A., et al. "Ultrasound evaluation of the penis for assessment of impotence." Journal of Clinical Ultrasound (1996 October) 24(8): 481-6.

Borirakchanyavat, S. and Tom F. Lue. "Evaluation of Impotence." (1997) Infectious Urology 10(1): 12-5, 18-23, 29.

Wahl, S.I., et al. "Radiologic evaluation of penile arterial anatomy in arteriogenic impotence." International Journal of Impotence Research (1997 June) 9(2): 93-7.

"Erectile Dysfunction." BCBSA Consortium Health Plan Medical Policy Reference Manual (1997 June 30) Medicine: 2.01.25.

Aggour, A., et al. "Evaluation of the role of corpus cavernosum electromyography as a noninvasive diagnostic tool in male erectile dysfunction." International Urology and Nephrology (1998) 30(1): 75-9.

Timmermans, L. "Methodology of penile isotope imaging. Evaluation." ACTA Urologcia Belgica (1998 March) 66(1): 13-7.

Policy History:

Archived Document(s):

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