TRANSMITTAL #: 132

DATE:  04/10/2013

TRICARE CHANGE #: N/A

CHAMPVA POLICY MANUAL

CHAPTER: 2

SECTION: 36.1

TITLE: MALE GENITAL SYSTEM

AUTHORITY:  38 CFR 17.270(a) and 17.272(a)

RELATED AUTHORITY:  32 CFR 199.4(c)(2), (c)(3), (e)(3)(i)(B)(3), (e)(7), and (e)(8)(i)(E)

I. EFFECTIVE DATE(S)

August 26, 1985

II. PROCEDURE CODE(S)

CPT Codes:  53850-53852, 54000-54250, 54300-54390, 54420-54650, 55705, 55720, 55873, 55899 and 55970-55980

III. DESCRIPTION(S)

A.      The male genital system includes the male organs of reproduction.

B.      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.

IV. POLICY

A.      Services and supplies required in the diagnosis and treatment of illness or injury involving the male genital system are covered when appropriate based on benefit policy.

B.      A vasectomy, unilateral or bilateral, performed as an independent procedure, is covered .

C.      Diagnostic studies necessary to establish organic versus psychogenic impotence, such as lab work, psychiatric evaluation, doppler ultrasound, arteriography, cavernosography, cavernosometry, or electrophysiological testing are covered.

D.      Treatment of organic impotency is covered subject to all applicable provisions of other basic program benefits.

1.       Penile Implant.

a.       Insertion of an Food and Drug Administration (FDA) approved penile implant is covered when performed for organic impotence that has resulted from a disease process, trauma, radical surgery, or for correction of a congenital anomaly, or for correction of sex gender confusion/ambiguous genitalia, which is documented to have been present at birth.

b.       Removal and reinsertion of covered penile implants and associated surgical fees are covered.

2.       Hormone injections, non-injectable delivery system or intracavernosal injection for the treatment of organic impotency, are covered providing the drugs are FDA-approved and usage is considered generally accepted medical practice.

3.       External vacuum appliances for the treatment of organic impotency are covered providing the external appliance is FDA-approved and usage is considered generally accepted medical practice.

4.       Treatment of organic male impotence is covered only after thorough evaluation has been documented by the physician.

a.       Physician-prescribed medications for organic impotence, such as Viagra, Levitra, and Cialis, are covered.  

b.       Dispensing of prescribed medications must adhere to established clinical guidelines.  

c.        “Lost”, “stolen”, or “destroyed” tablets will not be replaced.

5.       Aortoiliac reconstruction, endarterectomy, and arterial dilatations for proximal lesions for the treatment of organic impotency are covered.

E.       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 sex gender confusion/ambiguous genitalia, which is documented to have been present at birth.

F.       Infertility testing and treatment, including correction of the physical cause of infertility, are covered.  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, sperm function tests, and bacteriologic investigation.  Therapy may include, but is not limited to, hormonal treatment, surgery, antibiotics, administration of HCG (Human Chorionic Gonadotropin), and/or radiation therapy, depending upon the cause.

G.      For information concerning an implantable urethral sphincter (see Chapter 2, Section 33.1, Urinary System).

H.      Cryosurgery for prostate cancer is covered (see Chapter 2, Section 3.5, Prostate Cancer).

V. EXCLUSION(S)

A.      Artificial insemination including any cost related to donors and semen banks.

B.      Arterial revascularization for distal lesions and venous leakage when treatment is for organic impotency.

C.      Cryosurgery for prostate metastases M or N is unproven.

D.      Electroejaculation.

E.       Intersex surgery except when performed to correct gender confusion/ambiguous genitalia, which is documented to have been present at birth.

F.       Penile implants and related services when performed for psychological impotence, transexualism, or such other conditions as gender dysphoria.

G.      Prophylactics (condoms).

H.      Prostate saturation biopsy.

I.        Sperm penetration assay (hamster oocyte penetration test or the zone-free hamster egg test) for in vitro fertilization (IVF).

J.        The reversal of a voluntary surgical sterilization procedure.

K.      Therapy for sexual dysfunctions or inadequacies (see Chapter 2, Section 16.10, Sexual Dysfunctions, Paraphilias and Gender Identity Disorders).  

L.       Testicular Prosthesis. Insertion of a testicular prosthesis and related services when performed for transsexualism or such other conditions as dysphoria.   

*END OF POLICY*