Medical Policy Updates

Notification of Policy Revisions Effective July 29, 2004 (Posted May 27,2004)

Medical Policy	Revision
Sexual Dysfunction Treatment, Female	Sexual Dysfunction Treatment policy separated. Name changed from Sexual Dysfunction Treatment to Sexual Dysfunction Treatment, Female. Removed references to male sexual dysfunction. Specialty Matched Consultant Advisory Panel review 8/4/03. Description, Benefits Application and Billing/Coding sections revised. Under "When covered", A.1.a.iv - changed to "Surgically induced decline in estrogen level (i.e., bilateral salpingo-oophorectomy); A.1.b - is now "Drug induced" with i. "medications: antihypertensive (B-Blockers), antidepressants, tricyclics and monoamine oxidase inhibitors; A.1.e - ii. changed to Cardiovascular disease & added iv. - Peripheral vascular disease; A.1.f - added iv. Parkinson's Disease; A.2.b. - added "and/or testosterone" Under "When not covered", second bullet, added Levitra and Cialis. Sources added. Notification given 5/27/04. Effective date 7/29/04.
Sexual Dysfunction Treatment, Male	Sexual Dysfunction Treatment policy separated. Name changed from Sexual Dysfunction Treatment to Sexual Dysfunction Treatment, Male. Removed references to female sexual dysfunction. Specialty Matched Consultant Advisory Panel review 5/23/03. Description, Benefits Application and Billing/Coding sections revised. Under "When covered" section A.1.a. - added v. Hyperthyroidism & vi. Hypothyroidism; A.1.b. is now Anatomic/Structural causes: i. Acquired: Peyronie's Disease, penile fibrosis & ii. Congenital: Congenital curvature/chordee, micropenis; A.1.c - removed alcohol as this is a lifestyle factor; A.1.d.iii - added Transurethral prostatectomy (TURP); A.1.e. - added iii. Penile trauma; A.1.f.ii - changed "Cardiac" to Cardiovascular Disease; A.1.f. added iv. Peripheral vascular disease; A.1.g. - added iv. Parkinson's Disease; A.2.b. - added Levitra and Cialis, added most BCBSNC benefit plans have a limit of 4 tablets per 30 days, added information re: caution in patients taking alpha-blockers; A.2.c. - Provided more information re: Penile injection therapy, listed several other drugs & separated MUSE into A.2.d with description of procedure; A.2.f. - added "Surgical" implantation of.....; A.2.g - Added criteria for coverage of surgical revascularization. Under "When not covered", second bullet, added Levitra and Cialis; added the following four bullets: Oral yohimbine therapy; Arterial reconstructive procedures, dorsal vein arterialization procedures, or penile venous occlusive surgery (e.g., venous ligation, dorsal vein ligation) in men with erectile dysfunction secondary to arteriosclerotic occlusive disease are considered investigational; Topical cream or gel containing vasodilators are considered investigational; Extracorporeal shock wave therapy (ESWT) for Peyronie's Disease is considered investigational. Revised "Policy Guidelines" section to be consistent with benefit plan limitations. Billing/Coding section: Added the following codes - 37788, 37790, 54360, G0280, J0270, J0275, J2440, J2760, S0090; listed codes 54400-54417 separately; removed code 64999 as it is designated for reporting "unlisted procedures". Notification given 5/27/04. Effective date 7/29/04.

Medical Policy

Revision

Sexual Dysfunction Treatment, Female

Sexual Dysfunction Treatment policy separated. Name changed from Sexual Dysfunction Treatment to Sexual Dysfunction Treatment, Female. Removed references to male sexual dysfunction. Specialty Matched Consultant Advisory Panel review 8/4/03. Description, Benefits Application and Billing/Coding sections revised. Under "When covered", A.1.a.iv - changed to "Surgically induced decline in estrogen level (i.e., bilateral salpingo-oophorectomy); A.1.b - is now "Drug induced" with i. "medications: antihypertensive (B-Blockers), antidepressants, tricyclics and monoamine oxidase inhibitors; A.1.e - ii. changed to Cardiovascular disease & added iv. - Peripheral vascular disease; A.1.f - added iv. Parkinson's Disease; A.2.b. - added "and/or testosterone" Under "When not covered", second bullet, added Levitra and Cialis. Sources added. Notification given 5/27/04. Effective date 7/29/04.

Sexual Dysfunction Treatment, Male

Sexual Dysfunction Treatment policy separated. Name changed from Sexual Dysfunction Treatment to Sexual Dysfunction Treatment, Male. Removed references to female sexual dysfunction. Specialty Matched Consultant Advisory Panel review 5/23/03. Description, Benefits Application and Billing/Coding sections revised. Under "When covered" section A.1.a. - added v. Hyperthyroidism & vi. Hypothyroidism; A.1.b. is now Anatomic/Structural causes: i. Acquired: Peyronie's Disease, penile fibrosis & ii. Congenital: Congenital curvature/chordee, micropenis; A.1.c - removed alcohol as this is a lifestyle factor; A.1.d.iii - added Transurethral prostatectomy (TURP); A.1.e. - added iii. Penile trauma; A.1.f.ii - changed "Cardiac" to Cardiovascular Disease; A.1.f. added iv. Peripheral vascular disease; A.1.g. - added iv. Parkinson's Disease; A.2.b. - added Levitra and Cialis, added most BCBSNC benefit plans have a limit of 4 tablets per 30 days, added information re: caution in patients taking alpha-blockers; A.2.c. - Provided more information re: Penile injection therapy, listed several other drugs & separated MUSE into A.2.d with description of procedure; A.2.f. - added "Surgical" implantation of.....; A.2.g - Added criteria for coverage of surgical revascularization. Under "When not covered", second bullet, added Levitra and Cialis; added the following four bullets: Oral yohimbine therapy; Arterial reconstructive procedures, dorsal vein arterialization procedures, or penile venous occlusive surgery (e.g., venous ligation, dorsal vein ligation) in men with erectile dysfunction secondary to arteriosclerotic occlusive disease are considered investigational; Topical cream or gel containing vasodilators are considered investigational; Extracorporeal shock wave therapy (ESWT) for Peyronie's Disease is considered investigational. Revised "Policy Guidelines" section to be consistent with benefit plan limitations. Billing/Coding section: Added the following codes - 37788, 37790, 54360, G0280, J0270, J0275, J2440, J2760, S0090; listed codes 54400-54417 separately; removed code 64999 as it is designated for reporting "unlisted procedures". Notification given 5/27/04. Effective date 7/29/04.