Nerve Graft with Radical Prostatectomy Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 08|01|2017 POLICY LAST REVIEWED: 01|21|2026 OVERVIEW Nerve grafting at the time of radical prostatectomy, most commonly using the sural nerve, has been proposed to reduce the risk of postoperative erectile dysfunction. MEDICAL CRITERIA Not applicable
PRIOR AUTHORIZATION
Not applicable POLICY STATEMENT Medicare Advantage Plans Unilateral or bilateral nerve graft is considered not covered in individuals who have had resection of one or both neurovascular bundles as part of a radical prostatectomy as the evidence is insufficient to determine the effects of the technology on health outcomes. Commercial Products Unilateral or bilateral nerve graft is considered not medically in individuals who have had resection of one or both neurovascular bundles as part of a radical prostatectomy as the evidence is insufficient to determine the effects of the technology on health outcomes. COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate section of the Benefit Booklet, Evidence of Coverage or Subscriber Agreement for services not medically necessary. BACKGROUND Erectile dysfunction is a common problem after radical prostatectomy. In particular, spontaneous erections are usually absent in men whose prostate cancer required bilateral resection of the neurovascular bundles as part of the radical prostatectomy procedure. Treatment A variety of noninvasive treatments are available, including vacuum constriction devices and intracavernosal injection therapy. However, spontaneous erectile activity is preferred by individuals. Studies have reported results from bilateral and unilateral nerve grafts, the latter involving resection of 1 neurovascular bundle. There has been interest in sural nerve grafting to replace cavernous nerves resection during prostatectomy. The sural nerve is considered expendable and has been extensively used in other nerve grafting procedures, such as brachial plexus and peripheral nerve injuries. As applied to prostatectomy, a portion of the sural nerve is harvested from 1 leg and then anastomosed to the divided ends of the cavernous nerve. Reports also indicate the use of other nerves (eg, genitofemoral nerve) for grafting. For individuals who have radical prostatectomy with resection of neurovascular bundles who receive nerve grafting, the evidence includes a randomized controlled trial (RCT), cohort studies, and case series. Relevant outcomes are functional outcomes, quality of life, and treatment-related morbidity. The RCT did not find that unilateral nerve grafting was associated with a statistically significant improvement in potency rates at 2 years post surgery. Cohort studies also did not result in better outcomes with nerve grafting. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. Medical Coverage Policy | Nerve Graft with Radical Prostatectomy

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

Clinical Input From Physician Specialty Societies and Academic Medical Centers
While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

In response to requests, input was received from 4 academic medical centers while this policy was under review in 2008; no input was received from physician specialty societies. Input from the 4 centers agreed that this procedure is considered investigational.

Practice Guidelines and Position Statements
Guidelines or position statements will be considered for inclusion in ‘Supplemental Information’ if they were issued by, or jointly by, a US professional society, an international society with US representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

National Comprehensive Cancer Network The National Comprehensive Cancer Network guidelines on the treatment of prostate cancer (v.1.2025) states: “Replacement of resected nerves with nerve grafts has not been shown to be beneficial” for recovery of erectile function after radical prostatectomy.

CODING Medicare Advantage Plans and Commercial Products There are no specific CPT code(s) describing sural nerve grafting of the cavernous nerves; the CPT codes describing nerve grafts specifically identify the anatomic site and do not include the cavernous nerves.

Therefore, CPT code 64999 (unlisted procedure, nervous system) should be used to describe the nerve harvest and grafting component of the procedure.

RELATED POLICIES Unlisted Procedures

PUBLISHED Provider Update, March 2026 Provider Update, July 2025 Provider Update, August 2024 Provider Update, June 2023 Provider Update, July 2022

REFERENCES

1. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer. Version 1.2025. https://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf. Accessed February 18, 2025.
2. Davis JW, Chang DW, Chevray P, et al. Randomized phase II trial evaluation of erectile function after attempted unilateralcavernous nerve-sparing retropubic radical prostatectomy with versus without unilateral sural nerve grafting for clinicallylocalized prostate cancer. Eur Urol. May 2009; 55(5): 1135-43. PMID 18783876
3. Kung TA, Waljee JF, Curtin CM, et al. Interpositional Nerve Grafting of the Prostatic Plexus after Radical Prostatectomy.Plast Reconstr Surg Glob Open. Jul 2015; 3(7): e452. PMID 26301141
4. Namiki S, Saito S, Nakagawa H, et al. Impact of unilateral sural nerve graft on recovery of potency and continencefollowing radical prostatectomy: 3-year longitudinal study. J Urol. Jul 2007; 178(1): 212-6; discussion 216. PMID 17499797

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

5. Rabbani F, Ramasamy R, Patel MI, et al. Predictors of recovery of erectile function after unilateral cavernous nerve graftreconstruction at radical retropubic prostatectomy. J Sex Med. Jan 2010; 7(1 Pt 1): 166-81. PMID 19686422
6. Siddiqui KM, Billia M, Mazzola CR, et al. Three-year outcomes of recovery of erectile function after open radicalprostatectomy with sural nerve grafting. J Sex Med. Aug 2014; 11(8): 2119-24. PMID 24903070

7. Souza Trindade JC, Viterbo F, Petean Trindade A, et al. Long-term follow-up of treatment of erectile dysfunction afterradical prostatectomy using nerve grafts and end-to-side somatic-autonomic neurorraphy: a new technique. BJU Int. Jun 2017; 119(6): 948-954. PMID 28093890

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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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