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 United States
(US) 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 (Current Procedural Terminology (CPT)
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 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 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 codes
55970 and 55980).
5.6 Reversal
of surgical sterilization (CPT 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 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 (Healthcare Common Procedure
Coding System (HCPCS) code C9747) is unproven.