S4988, Penile contracture device, manual, greater than 3 lbs traction force
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of a comprehensive history and physical exam in the medical record to support assessment of sexual dysfunction
- Documentation that contract benefits were checked when treating psychological or psychogenic sexual dysfunctions
- Record of intracavernosal injection (ICI) procedure and specific vasodilating agent used for pharmacologic testing and for imaging/flow studies.
- Doppler/sonography reports for penile brachial index and duplex/color Doppler studies documenting technique and hemodynamic measurements.
Key Coverage Criteria
- 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).
- Laboratory evaluation as part of erectile dysfunction workup including hormonal testing (testosterone, LH, FSH, prolactin), complete blood count, urinalysis, and thyroid function studies.
5 Active Policies
BCBSIL-MED201.030, Sexual Dysfunctions, Assessment and Treatment
BCBSMT-MED201.030, Sexual Dysfunctions, Assessment and Treatment
BCBSNM-MED201.030, Sexual Dysfunctions, Assessment and Treatment
BCBSOK-MED201.030, Sexual Dysfunctions, Assessment and Treatment
MED201.030, Sexual Dysfunctions, Assessment and Treatment
Related Codes
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