80197
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
- For investigational or experimental therapies (e.g., BoNT‑A ICI, PRP, stem cell therapies, ADRC, gene therapy, many shockwave modalities): documentation that treatment is being delivered in the context of a clinical trial or research protocol is appropriate given statements that these should be limited to clinical studies and that more evidence is needed.
- No other explicit clinical documentation requirements (e.g., required test results, prior treatments, or specific clinical findings) are stated in this excerpt; medical necessity must be demonstrated via the referenced 'selection criteria' which are not included in this chunk.
- For J0775 (collagenase): the excerpt includes 'Not covered for cosmetic use (e.g., cellulite reduction treatment)' — documentation should support non-cosmetic, medically indicated use.
Key Coverage Criteria
- Corpora cavernosography and cavernosal injection diagnostic procedures (CPT 74445, 54230-54235) when selection criteria are met.
- Therapeutic injections specifically listed as covered when selection criteria met: alprostadil injection (J0270) and alprostadil urethral suppository (J0275) — note: may be used for Medicare when administered under direct supervision of a physician and not for self-administered use.
- Collagenase clostridium histolyticum (Xiaflex) injection (HCPCS J0775) for indicated Peyronie's disease diagnoses (ICD-10: N52.01 - N52.1; N52.31 - N52.39) when selection criteria are met.
- Vacuum erection system (HCPCS L7900) and tension rings for vacuum device (HCPCS L7902) — L7902 coverage limited to replacement only, when selection criteria met.
- A range of laboratory and diagnostic tests commonly used in ED/Peyronie’s evaluation are covered when selection criteria are met, including: lipid panel (80061), hepatic function panel (80076), urinalysis (81000-81003), serum creatinine (82565), blood glucose (82947), FSH/LH (83001-83002), LH-related (83727), prolactin (84146), PSA (84152-84154), testosterone total/free/bioavailable (84402-84403; 84410), TSH (84443), T3/T4 uptake or THBR (84479), CBC (85025-85027), and others listed in the code [...]
- Other listed diagnostic and physiologic tests relevant to ED/penile disorders when selection criteria are met (e.g., corpora cavernosography CPT 74445, ultrasound of penile vessels CPT 93980-93981, nerve conduction/SSEP studies where relevant: CPT 95907-95913/95925-95927).
1 Active Policy
AETNA-CPB-0007 — Erectile Dysfunction
Related Codes
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