4.0 POLICY
4.1 Medically necessary services and supplies required
in the diagnosis and treatment of disease or injury involving the
male genital system are covered.
4.2 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.)
4.4 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.)
4.5 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.
4.6 Treatment
of organic impotency is covered subject to all applicable provisions
of
32 CFR 199.4.
4.6.1 Penile Implant.
4.6.1.1 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.
4.6.1.2 Removal
and reinsertion of covered penile implants and associated surgical
fees may be cost-shared.
4.6.2 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.
4.6.3 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.
4.6.4 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).
4.6.5 Aortoiliac reconstruction, endarterectomy,
and arterial dilatations for proximal lesions for the treatment
of organic impotency may be cost-shared.
4.6.6 Testicular prostheses.
4.6.6.1 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.
4.6.6.2 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.
4.6.6.3 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.
4.7 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.
4.8 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.
4.9 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.
4.10 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.
5.0 EXCLUSIONS
5.1 Penile implants and related services when performed
for psychological impotence, sex gender change surgery, or such
other conditions as gender dysphoria.
5.2 Testicular prosthesis and related services
when performed for sex gender change surgery or such other conditions
as gender dysphoria.
5.4 Arterial revascularization for distal lesions
and venous leakage when treatment is for organic impotency.
5.5 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).
5.6 Reversal of surgical sterilization (CPT procedure
codes 54900, 54901, and 55400), except as stated in
paragraph 4.9.
5.7 Cryosurgery for prostate metastases M or N
is unproven.
5.8 Electroejaculation
(CPT procedure code 55870).
5.9 Prophylactics (condoms).
5.10 Over-The-Counter (OTC) spemicidal products.
5.11 Penile Vibratory Stimulation (PVS) devices,
such as Ferticare Personal 2 medical vibrator.
5.12 High-Intensity Focused Ultrasound (HIFU) for
the treatment of prostate cancer (HCPCS code C9747) is unproven.