CPT 54360, in plain terms, covers Reconstructive plastic surgery on the penis to straighten a shaft that bends or angles abnormally. This is corrective work, not a cosmetic service. CPT 54360 is referenced in 3 tracked payer policy changes from Nevada Medicaid, Aetna, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 54360 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 54360 on AAPC
Nevada Medicaid now requires prior authorization for specific gender dysphoria surgical procedures when billed with certain diagnosis codes (F64.0, F64.1, F64.2, F64.8, F64.9, or Z87.890). Six specific procedure codes are affected, and modifier KX or condition code 45 is still required for transgender patient claims.
Aetna considers the diagnosis and treatment of erectile dysfunction medically necessary under the criteria in its policy, including self-administered injectable medications, the external penile vacuum pump as a physician-prescribed durable medical equipment alternative to other therapies, and implantable penile prostheses when the documented criteria are met. Surgical correction of Peyronie's disease, such as plaque excisions, venous graft patching, tunica plication or the Nesbit tuck, is medically necessary for members who have the condition for 12 or more months with significant morbidity and have failed conservative medical treatment. Many other treatments, including extracorporeal shock wave therapy and testosterone injection for Peyronie's disease and stem cell therapy for erectile dysfunction, are considered experimental, investigational, or unproven.
This medical policy and coding update for WA and Alaska lists changes with effective dates from September 1, 2019 through January 3, 2020. Several medical policies state that a service may be considered medically necessary when criteria are met, while others are considered investigational, including irreversible electroporation (NanoKnife System) and implantable peripheral nerve stimulation for chronic pain. Coding updates effective October 1, 2019 add codes that now require review for medical necessity and prior authorization, including J1303, J9204, J0593, J9118 and Q5116.
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