Deep Dorsal Vein Arterialization Revascularization Procedure

POLICY NUMBER

L.7.01.420

DESCRIPTION

Used for the treatment of arteriogenic impotence or vasculogenic impotence that is often another diagnostic term. Deep dorsal vein arterialization is a well-recognized method of revascularizing the corpora cavernosa with the penis for the non-prosthetic treatment of arteriogenic impotence. This procedure is indicated in those males with objectively documented arteriogenic or vasculogenic impotence in whom a thorough work-up has ruled out other causes of the erectile dysfunction and in whom, objectively, it can be demonstrated that the patient has either unilateral or bilateral pudendal artery, dorsal penile artery, and cavernosal artery disease, and/or occlusion by standard techniques of pelvic arteriography. The procedure may be combined with a venous ligation procedure in those patients who have a mixed lesion, both arteriogenic and venogenic. The Society for the Study of Impotence, and ad hoc committee of the American Urological Association, Inc., has approved this procedure for treatment as indicated above in accordance with specific guidelines and criteria for patient selection.

POLICY

Benefits are specifically excluded for services and supplies for treatment related to sex transformations, sexual function, sexual dysfunctions or inadequacies regardless of medical necessity.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

POLICY HISTORY

3/1993: Approved by Medical Policy Advisory Committee (MPAC)

4/5/2001: Policy reviewed; Managed Care Requirements deleted

4/18/2002: Type of Service and Place of Service deleted

6/5/2002: Code Reference section completed

8/4/2005: Code Reference section updated, ICD-9 procedure code 39.99 deleted, ICD-9 procedure code 64.98 added

1/30/2007: Policy reviewed, no changes

10/30/2013: Policy reviewed; no changes.

08/21/2015: Code Reference section updated for ICD-10.

06/01/2016: Policy number L.7.01.420 added.

10/13/2022: Policy reviewed; no changes.

10/18/2023: Policy reviewed; no changes.

11/07/2024: Policy reviewed; no changes.

SOURCE(S)

1. Master Contract (1991)

2. The Center for Urological Treatment and Research

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

Non-Covered Codes

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