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.)
3.4 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.
4.4 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.