Erectile Dysfunction and Peyronie's Disease (CPB 0007, reviewed 2026-07-29)

REQUIREMENTS: - Immediately: Billing team must review Aetna benefit plan documents to confirm whether ED/Peyronie's treatments are excluded under member's specific plan (some traditional medical plans exclude sexual dysfunction coverage entirely). - Before submitting claims: Verify that diagnostic workup includes only Aetna-approved tests (biothesiometry, blood glucose, CBC, creatinine, hepatic panel, lipid profile, PSA, testosterone, thyroid studies, urinalysis). Do NOT bill for experimental tests listed in policy (e.g., cavermap mapping, dorsal nerve conduction latencies, genetic polymorphism testing, serum biomarkers). - For injectable medications (papaverine, alprostadil, phentolamine, MUSE): Confirm in-office titrating doses and physician-administered diagnostic injections are billed; ensure they align with member's pharmacy benefit (sildenafil, vardenafil, tadalafil may require optional rider or state mandate). - For penile prosthesis implants: Before processing authorization, confirm member meets ALL criteria: documented organic disease, normal prolatin/thyroid/testosterone (except for surgical/radiation/trauma cases), failed nonsurgical methods, no active substance abuse, no untreated psychiatric illness. - For penile re-vascularization: Restrict coverage to members under 55 years old with focal arterial blockage documented by duplex Doppler or arteriography; obtain prior authorization and supporting imaging before scheduling. - Educate providers: Communicate that external penile pumps are only covered for ED treatment (not prevention post-prostatectomy) and that NPT testing with postage stamp/snap gauge is rarely necessary. - Consequence of non-compliance: Claims for non-covered diagnostic tests, experimental treatments, or procedures not meeting medical necessity criteria will be denied.