L30870-LCD

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Local Coverage Determination (LCD) for Duplex scan for erectile dysfunction (L30870)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L30870

LCD Title

Duplex scan for erectile dysfunction

Contractor's Determination Number 93980

Primary Geographic Jurisdiction opens in new window

Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 06/07/2010

Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy N/A

Indications and Limitations of Coverage and/or Medical Necessity

A duplex scan (also known as duplex ultrasonography) is a simple, painless, non-invasive examination that uses sound waves to take images of the blood vessels and blood flow. It allows detailed assessment of the major veins and arteries.

Duplex scan is used to evaluate blood flow, venous leak, signs of artherosclerosis, and scarring or calcification of erectile tissue. Erection is induced by injecting prostaglandin, a hormone-like stimulator produced in the body. Ultrasound is then used to visualize vascular dilation and measure penile blood pressure (which may also be measured with a special cuff). Measurements are compared to those taken when the penis is flaccid. Duplex scan of the penile vessels is a diagnostic study. It should not be used for routine monitoring in a rehabilitation protocol or post-operative follow-up protocol.

Indications

Duplex scan of the penile vessels will be considered medically reasonable and necessary for

• The treatment failure of erectile dysfunction in patients who have sustained a documented groin, pelvic or vascular injury where a vascular etiology for impotence is suspected.

• The differentiation of ischemic priapism from non ischemic priapism for determining appropriate medical management.

• Patients with a lifetime history erectile dysfunction.

• For assisting in determining whether the cause of erectile dysfunction is psychogenic or vascular in origin.

• Peyronie’s Disease

Limitations

Duplex scan of the penile vessels will be considered not medically reasonable and necessary

• when not preceded by pharmacological/medicinal treatment

• when performed as a routine procedure

• when the outcome is not contributory to a plan of treatment

Training and Education

All non-invasive vascular diagnostic studies must be: (1) performed by a qualified physician, or (2) performed under the general supervision of a qualified physician by a technologist who has demonstrated minimum entry level competency by being credentialed in vascular technology, and/or (3) performed in a laboratory accredited in vascular technology.

Examples of certification in vascular technology for non-physician personnel include:

• Registered Vascular Technologist (RVT) credential

• Registered Vascular Specialist (RVS) credential

These credentials must be provided by nationally recognized credentialing organizations such as:

• The American Registry of Diagnostic Medical Sonographers (ARDMS) which provides RDMS and RVT credentials

• The Cardiovascular Credentialing International (CCI) which provides RVS credential Appropriate nationally recognized laboratory accreditation bodies include:

• Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL)

• American College of Radiology (ACR)

General Supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

93980 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF PENILE VESSELS; COMPLETE STUDY

93981 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF PENILE VESSELS; FOLLOW-UP OR LIMITED STUDY

ICD-9 Codes that Support Medical Necessity

302.72 PSYCHOSEXUAL DYSFUNCTION WITH INHIBITED SEXUAL EXCITEMENT

607.3 PRIAPISM

607.82 VASCULAR DISORDERS OF PENIS

607.84 IMPOTENCE OF ORGANIC ORIGIN

607.85 PEYRONIE'S DISEASE

902.89 INJURY TO OTHER SPECIFIED BLOOD VESSELS OF ABDOMEN AND PELVIS

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

The medical record should include a thorough patient history and physical examination which includes sexual history, a history of medications which can cause erectile dysfunction, past medical history including the identification of medical conditions that can contribute to impotence, psychological risk factors, conflicts with partner associated with increased anxiety and tension.

Duplex scan of the penis performed due to erectile dysfunction should include documentation which supports all of the following

• Penile response to pharmacotesting is suboptimal or unchanged PRIOR to the performance of the duplex scan

• Failure of treatment modality for erectile dysfunction

• The outcome of the duplex scan will be contributory to the decision making process and/or provide additional information relevant to the patient’s care

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to medical review.

Studies ordered for routine monitoring will not be covered.

Sources of Information and Basis for Decision

American Urological Association clinical guidelines. Management of erectile dysfunction (‘05/Updated’06)

American Urological Association. The management of erectile dysfunction: An update. June 2007 American urological association education and research, inc.&reg

American Urological Association. Guideline on the management of priapism. American urological association education and research, inc. 2003

Bhatt S, Ghazale H, Dogra V. Sonographic evaluation of scrotal and penile trauma. Ultrasound clin 2 (2007) 45-

56. Retrieved from MD Consult 12/30/2009

Chalabi H, Ghalib, H, et al. Pilonidal sinus of the penis. Case report. Infection and drug resistance 2008:1-13-15 Abstract

Futterer, J, Heijmink S, Spermon J R. Imaging the male reproductive tract: current trends and future directions.

Radiol Clin N AM, 46 (2008) 133-147. retrieved from MD Consult on 12/30/2009.

Lue T F, Groderick, G A. Evaluation and nonsurgical management of erectile dysfunction and premature ejaculation. Wein: Campbell-Walsh Urology, 9th ed (pp 757-760) Retrieved from MD consult on 12/30/2009

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from numerous societies.

Florida Contractor Advisory Committee meeting February 13, 2010

Puerto Rico/U.S. Virgin Islands Contractor Advisory Committee meeting February 25, 2010

Start Date of Comment Period 02/04/2010

End Date of Comment Period 03/20/2010

Start Date of Notice Period 04/23/2010

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:02/04/2010

Start Date of Notice Period:04/23/2010 Original Effective Date:06/07/2010

LCR B2010 - 040

April 2010 Update

Reason for Change