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.