Policy Updates Prior AuthorizationMedicaidSeptember 1, 2023

Existing New York State Medicaid policy for drugs, supplies, and procedures used for sexual or erectile dysfunction

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

In accordance with Chapter 645 of the Laws of 2005, the New York State Medicaid program does not cover prescription or physician administered drugs used for the treatment of sexual dysfunction (SD) or erectile dysfunction (ED). Additionally, Medicaid does not reimburse any supplies or procedures used to treat SD/ED for persons required to register as sex offenders. Providers must verify that Medicaid members receiving any procedures or supplies that may be used for these indications are not listed as registered sex offenders.

Medicaid Managed Care (MMC) plans

Prior to approving requests for any SD/ED related drugs, supplies, or procedures, MMC plans (including mainstream MMC plans, HIV Special Needs Plans [SNPs], and Health and Recovery Plan [HARP] programs) are required to submit requests for information regarding enrollee status on the sex offender registry to the New York State Department of Health through the Health Commerce System (HCS) Erectile Dysfunction Verification System (EDVS) each time there are requests for these services.

New York State Medicaid fee-for-service has compiled the following list of services used for the treatment of SD/ED:

CPT® codes and physician-administered (J‑code) drugs

Description

37788

Penile revascularization, artery, with or without vein graft

37790

Penile venous occlusive procedure

54400

Insertion of penile prosthesis; non-inflatable (semi-rigid)

54401

Insertion of penile prosthesis; inflatable (self-contained)

54405

Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir

54408

Repair of component(s) of a multi-component, inflatable penile prosthesis

54410

Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session

54411

Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue

54416

Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session

54417

Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue

55870

Electroejaculation

J0270

Injection, alprostadil, 1.25 mcg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) *

J0275

Alprostadil urethral suppository (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) *

J0775

Injection, collagenase, clostridium histolyticum, 0.01 mg

J2440

Injection, papaverine hydrochloride injection (HCI), up to 60 mg

J2760

Injection, phentolamine mesylate, up to 5 mg

L7900

Male vacuum erection system

L7902

Tension ring, for vacuum erection device, any type, replacement only, each

* Please note: In the inpatient setting, alprostadil and papaverine may be covered for the treatment of a condition other than sexual or erectile dysfunction for which the drugs have been approved by the FDA. Additionally, physician-administered collagenase, clostridium histolyticum, and phentolamine mesylate may be covered for the treatment of a condition, other than sexual or erectile dysfunction, for which the drug has been approved by the FDA and prior approval has been received.

All the above codes need to be checked in the state system before they are reviewed for medical necessity.

NYBCBS-CD-034147-23

PUBLICATIONS: September 2023 Provider Newsletter