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.