Prior authorization request form Form

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Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate care.
EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary.
If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.
EmblemHealth may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. EmblemHealth Services Company, LLC, has adopted this policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc.

Note pertaining to New York State Medicaid and Family Health Plus Plans: Chapter 645 of the Laws of 2005 excludes from coverage procedures and supplies for the treatment of erectile dysfunction when provided to, or prescribed for use by, a person who is required to register as a sex offender under the state law. Overview A penile prosthesis is a plastic device surgically implanted inside the penis in order to simulate an erection. There are two types of prostheses:

Semi-rigid (nonhydraulic): A semi-rigid but malleable rod. The semi-rigids are further divided into malleable and mechanical devices. Malleable prostheses are made of silicone rubber with an intertwined metallic core. Mechanical prostheses are also made of silicone rubber, with a column of interlocking rings that provide rigidity when they are lined up and flaccidity when the penis is bent.
Inflatable (hydraulic): A device that can be inflated with fluid to stiffen the penis. Inflatable prostheses may be comprised of 1, 2 or 3 pieces. The 1-piece device consists of a pair of hydraulic cylinders implanted within the corpora cavernosa. A pump at the distal end cycles fluid from a rear tip reservoir into a central chamber to produce penile rigidity.
Most devices will warrant replacement within 10 to 15 years. Surgical repair, removal or replacement of the prosthesis may also become necessary due to malfunction or patient complications.

Page 2 of 3 Indications for Coverage Penile implants are considered medically necessary for members ≥ 18 years of age when any of the following are documented as causal to erectile dysfunction:  Failure or contraindication of alternative therapy (e.g., PDE-V inhibitors, vacuum devices or intracavernous injections)  History of prostate, bladder, bowel or spinal surgery (e.g., cystectomy, prostatectomy, partial penectomy, abdominal-perineal resection, anterior exenteration or pelvic exenteration)  Injury to genitalia or perineum  Neurologic disease (e.g., diabetic neuropathy)  Paraplegia or quadriplegia  Pelvic radiation  Pelvic trauma with urinary system injury  Peyronie’s disease  Renal failure  Vascular insufficiency or venous incompetence (venous leak)  Vascular surgery with aorta or femoral vessel involvement  Members with gender dysphoria in association with gender affirming surgery For coverage of organic conditions that are not listed above, documentation must indicate all other failed treatment modalities. Circumcision may be indicated for patients with phimosis and balanitis. Implants may not be appropriate for patients with severe penile corporal fibrosis or severe medical illness. Limitations and Exclusions Penile implantation is not covered in the documented presence of any of the following:  Psychogenic erectile dysfunction, which may be manifested as follows:

Inhibited sexual excitement
Inhibited orgasm
Premature ejaculation
Functional dyspareunia  Alcohol or substance abuse.  Any untreated medical condition. Procedure Codes
54400 Insertion of penile prosthesis; non-inflatable (semi-rigid) 54401 Insertion of penile prosthesis; inflatable (self-contained) 54405 Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir 54408 Repair of component(s) of a multi-component, inflatable penile prosthesis 54410 Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session 54411 Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue 54416 Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same

Page 3 of 3 operative session 54417 Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue

ICD-10 Diagnoses All diagnoses References Burnett AL. Evaluation and Management of Erectile Dysfunction. In Campbell-Walsh’s Urology, 10th edition. Philadelphia: WB Saunders, Chapter 24, 2011.
AUA Guidelines: Erectile Dysfunction.
http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/edmgmt/chapter1.pdf
Porst H, Burnett A, Brock G, Ghanem H, Giuliano F, Glina S, Hellstrom W, Martin-Morales A, Salonia A, Sharlip I; ISSM Standards Committee for Sexual Medicine. SOP conservative (medical and mechanical) treatment of erectile dysfunction. J Sex Med. 2013 Jan;10(1):130-71.
Specialty matched clinical peer review. Revision History Company(ies)

  DATE

REVISION EmblemHealth Feb 14, 2025 Transferred policy content to individual company branded template EmblemHealth ConnectiCare Feb. 11, 2022 Feb. 11, 2022 Reinstated New Policy

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Prior authorization request form Form

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