S0090, Sildenafil citrate, 25 mg
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
- Laboratory values as applicable (e.g., PSA measurements reported in many trials and used as a secondary outcome).
- Imaging/angiographic documentation for PAE (prostatic arterial anatomy identification) and documentation of technical feasibility or reasons for technical failure.
- Erectile and ejaculatory function assessment (IIEF-5 or IIEF-15, MSHQ, MSHQ-EjD, SHIM) where preservation of sexual function is a treatment goal.
- Adverse event reporting classified by Clavien-Dindo grading (many studies used this to grade complications).
Key Coverage Criteria
- ICD-10 codes covered if selection criteria are met: N35.010 - N35.92 Urethral stricture
- PAE can be considered in patients with hematuria of prostatic origin as a method of achieving cessation of bleeding. (Level of Evidence: D; strength of recommendation: strong)
- Alpha adrenergic blockers (alfuzosin, doxazosin, silodosin, tamsulosin, and terazosin)
- Aquablation (AquaBeam, water jet hydrodissection)
- Hormonal manipulation (including finasteride, dutasteride, and dutasteride plus tamsulosin)
- Interstitial laser coagulation of the prostate (ILCP)
8 Active Policies
AETNA-CPB-0079, Benign Prostatic Hyperplasia
AETNA-CPB-0327, Infertility
AETNA-CPB-0184, Pulmonary Hypertension Treatments and Selected Indications of Prostanoids
MED201.030, Sexual Dysfunctions, Assessment and Treatment
BCBSIL-MED201.030, Sexual Dysfunctions, Assessment and Treatment
Related Codes
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