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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 15.1
Male Genital System
Issue Date:  August 26, 1985
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-45, April 26, 2019
1.0  CPT PROCEDURE CODES
54000 - 55300, 55400, 55450 - 55705, 55720 - 55866, 55873 - 55899, 55970, 55980
2.0  DESCRIPTION
The male genital system includes the male organs of reproduction.
3.0  POLICY
3.1  Medically necessary services and supplies required in the diagnosis and treatment of disease or injury involving the male genital system are covered.
3.2  A vasectomy, unilateral or bilateral, performed as an independent procedure is a covered service. (See Chapter 7, Section 2.3 for detailed policy concerning sterilization and birth control.)
3.3  For Implantable Urethral Sphincter, see Section 14.1.
3.4  Diagnostic studies necessary to establish organic versus psychogenic impotence, such as lab work, a psychiatric evaluation, Doppler ultrasound, arteriography, cavernosography, cavernosometry, or electrophysiological testing may be cost-shared. (Also, see Chapter 7, Section 1.1.)
3.5  Organic impotence is defined as that which can be reasonably expected to occur following certain diseases, surgical procedures, trauma, injury, or congenital malformation. Impotence does not become organic because of psychological or psychiatric reasons.
3.6  Treatment of organic impotency is covered subject to all applicable provisions of 32 CFR 199.4.
3.6.1  Penile Implant.
3.6.1.1  Insertion of an U.S. Food and Drug Administration (FDA) approved penile implant is covered when performed for organic impotence which has resulted from a disease process, trauma, radical surgery, or for correction of a congenital anomaly, or for correction of ambiguous genitalia which has been documented to be present at birth.
3.6.1.2  Removal and reinsertion of covered penile implants and associated surgical fees may be cost-shared.
3.6.2  Hormone injection, non-injectable delivery system or intracavernosal injection for the treatment of organic impotency, may be cost-shared providing the drugs are FDA approved and usage is considered generally accepted medical practice.
3.6.3  External vacuum appliance for the treatment of organic impotency may be cost-shared providing the external appliance is FDA approved and usage is considered generally accepted medical practice.
3.6.4  Orally administered medication for the treatment of erectile dysfunction may be cost-shared. Prior authorizations and quantity limits may be required (see Chapter 8, Section 9.1).
3.6.5  Aortoiliac reconstruction, endarterectomy, and arterial dilatations for proximal lesions for the treatment of organic impotency may be cost-shared.
3.6.6  Testicular prostheses.
3.6.6.1  Insertion of an FDA approved testicular prosthesis is covered when performed following disease, trauma, injury, radical surgery, or for correction of a congenital anomaly, or for correction of ambiguous genitalia which has been documented to be present at birth.
3.6.6.2  If the initial testicular prosthesis surgery was for an indication covered or coverable by TRICARE, treatment of complications may be covered following reconstruction (including prosthesis removal and reinsertion) regardless of when the reconstruction was performed. Complications that may result following removal and reinsertion of prostheses are covered.
3.6.6.3  If the initial testicular prosthesis surgery was for an indication not covered or coverable by TRICARE, implant removal may be covered only if it is necessary treatment of a complication which represents a separate medical condition. See Section 1.1.
3.7  Infertility testing and treatment, including correction of the physical cause of infertility may be cost-shared. Hypothalamic disease, pituitary disease, disorders of sperm transport, disorders of sperm motility or function, and/or sexual dysfunction may cause male infertility. Diagnostic Services may include semen analysis, hormone evaluation, chromosomal studies, immunologic studies, special and sperm function tests, and/or bacteriologic investigation. Therapy may include, but is not limited to, hormonal treatment, surgery, antibiotics, administration of Human Chorionic Gonadotropin (HCG), and/or radiation therapy, depending upon the cause.
3.8  Sex gender change and intersex surgery (CPT procedure codes 55970 and 55980) is limited to surgery performed to treat ambiguous genitalia which is documented to have been present at birth.
3.9  Medically necessary reversal of surgical sterilization for the treatment of a disease or injury such as intractable chronic scrotal pain or post-vasectomy pain (CPT procedure codes 55400, 54900, and 54901) may be cost-shared.
3.10  Effective April 14, 2016, prostate saturation biopsy for men at risk for prostate cancer, with one previous negative biopsy, with abnormal Digital Rectal Exam (DRE), with elevated or rising Prostate-Specific Antigen (PSA) levels and/or abnormal findings on previous biopsies (CPT procedure code 55706) is covered.
4.0  EXCLUSIONS
4.1  Penile implants and related services when performed for psychological impotence, sex gender change surgery, or such other conditions as gender dysphoria.
4.2  Testicular prosthesis and related services when performed for sex gender change surgery or such other conditions as gender dysphoria.
4.3  Therapy for sexual dysfunctions or inadequacies (see Chapter 7, Section 1.1).
4.4  Arterial revascularization for distal lesions and venous leakage when treatment is for organic impotency.
4.5  All services and supplies directly and indirectly related to surgical treatment (i.e., sex gender change), except when performed to correct ambiguous genitalia, which is documented to have been present at birth (CPT procedure codes 55970 and 55980).
4.6  Reversal of surgical sterilization (CPT procedure codes 54900, 54901, and 55400), except as stated in paragraph 3.9.
4.7  Cryosurgery for prostate metastases M or N is unproven.
4.8  Electroejaculation (CPT procedure code 55870).
4.9  Prophylactics (condoms).
4.10  Over-The-Counter (OTC) spemicidal products.
4.11  Penile Vibratory Stimulation (PVS) devices, such as Ferticare Personal 2 medical vibrator.
4.12  High-Intensity Focused Ultrasound (HIFU) for the treatment of prostate cancer (HCPCS code C9747) is unproven.
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