LCD/NCD Portal

L30870

 

DUPLEX SCAN FOR ERECTILE DYSFUNCTION

 

06/07/2010

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Indications

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

o 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.

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

o Patients with a lifetime history erectile dysfunction.

o 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:

o Registered Vascular Technologist (RVT) credential

o Registered Vascular Specialist (RVS) credential

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

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

o 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.

o 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.

 

 

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

 

 

Documentation Requirements

• The medical record should include a thorough patient history and physical examination which includes

o sexual history,

o a history of medications which can cause erectile dysfunction,

o past medical history including the identification of medical conditions that can contribute to impotence,

o psychological risk factors,

o 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

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

o Failure of treatment modality for erectile dysfunction

o 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

Utilization Guidelines

• Studies ordered for routine monitoring will not be covered.

 

Treatment Logic

• 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.

o 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.

o Erection is induced by injecting prostaglandin, a hormone-like stimulator produced in the body.

o Ultrasound is then used to visualize vascular dilation and measure penile blood pressure (which may also be measured with a special cuff).

o Measurements are compared to those taken when the penis is flaccid.

o Duplex scan of the penile vessels is a diagnostic study.

o It should not be used for routine monitoring in a rehabilitation protocol or post-operative follow-up protocol.

 

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.®

 

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

 

06/07/2010

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD DUPLEX SCAN FOR ERECTILE DYSFUNCTION