Anthem Blue Cross Connecticut CG-SURG-12 Penile Prosthesis Implantation Form
This procedure is not covered
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.
Clinical Indications
Medically Necessary:
The implantation of a penile prosthesis is considered medically necessary for individuals who meet the following criteria:
- Have erectile dysfunction of greater than 6 months duration; and
- Experienced failure of or have contraindication to less invasive treatments including one or more of the following:
- Oral medication; or
- Intracavernosal injection; or
- Vacuum constriction device.
The implantation of a replacement penile prosthesis is considered medically necessary for individuals who meet the following criteria:
- The individual is likely to obtain continued benefit derived from use of the device; and
- One of the following:
- The device experienced mechanical failure; or
- 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.
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