0864T — Low ntsty eswt corpus cvrnsm
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- No explicit or itemized documentation requirements (medical records, tests, prior conservative treatments, etc.) are specified in this policy.
- Policy instructions require reference to the member-specific benefit plan document when deciding coverage: "When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan."
- Before applying the policy, check member-specific benefit plan document and applicable federal or state mandates: "Before using this policy, please check the member specific benefit plan document and any applicable federal or state mandates."
- Documentation of a comprehensive history and physical exam in the medical record to support assessment of sexual dysfunction
Key Coverage Criteria
- "Extracorporeal shock wave therapy (ESWT), whether low energy, high energy, or radial wave, is unproven and not medically necessary for any musculoskeletal or soft tissue indications due to insufficient evidence of efficacy."
- Comprehensive history and physical examination for assessment of sexual dysfunction in males and females
- Pharmacologic screening for erectile dysfunction using intracavernosal injection (papaverine, phentolamine, or prostaglandin E1).
- Assessment of nocturnal penile tumescence and rigidity (morning sleep nap) to evaluate erectile function.
- Evaluation of penile arterial inflow/arterial insufficiency (penile brachial index, pudendal arteriography with ICI, angiography with ICI, duplex/color Doppler sonography with ICI).
- Assessment for veno-occlusive dysfunction (cavernosography with radiocontrast and ICI; cavernosometry with saline infusion, with or without ICI).
8 Active Policies
UHC-POL-extracorporeal-shock-wave-therapy — Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications
UMR-POL-UMR-extracorporeal-shock-wave-therapy — Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications
SUREST-POL-SUREST-extracorporeal-shock-wave-therapy — Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications
BCBSIL-MED201.030 — Sexual Dysfunctions, Assessment and Treatment
Related Codes
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