CG-SURG-12 Penile Prosthesis Implantation Form

This document addresses the criteria for implantation of a penile prosthesis, which is an established technique for treating erectile dysfunction (ED).

Note: This document does not address gender affirming surgery or procedures. Criteria for gender affirming surgery or procedures are found in applicable guidelines used by the plan.

Medically Necessary:

The implantation of a penile prosthesis is considered medically necessary for individuals who meet the following criteria:

1. Have erectile dysfunction of greater than 6 months duration; and
2. Experienced failure of or have contraindication to less invasive treatments including one or more of the following:
   1. Oral medication; or
   2. Intracavernosal injection; or
   3. Vacuum constriction device.  

The implantation of a replacement penile prosthesis is considered medically necessary for individuals who meet the following criteria:

1. The individual is likely to obtain continued benefit derived from use of the device; and
2. One of the following:
   1. The device experienced mechanical failure; or
   2. The individual has a medical indication for device removal.

Not Medically Necessary:

The implantation of a penile prosthesis is considered not medically necessary when the above criteria are not met.