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Date Printed: June 25, 2017: 01:19 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-54000-20

Original Effective Date: 03/15/04

Reviewed: 12/03/09

Revised: 05/11/14

Subject: Extracorporeal Shock Wave Therapy in the Treatment of Peyronie’s Disease

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates  

DESCRIPTION:

Peyronie’s disease is an acquired inflammatory disease of the tunica albuginea and adjacent erectile tissue of the penis, most commonly affecting men between the ages of 45 and 60 years old. In the acute inflammatory stage, the patient may experience pain during flaccidity and/or during erection or sexual intercourse. The pain usually resolves over several months as the acute inflammation subsides, and the condition evolves to a progressive fibrosis with development of a palpable plaque. The plaque may result in curvature of the penis, erectile dysfunction, or distal flaccidity. In some patients the plaque may resolve and disappear entirely. The etiology of Peyronie’s is unknown, but is thought to be related to subclinical trauma.

Patients may seek treatment both for relief of pain during the acute inflammatory phase, and the sexual dysfunction and distortion characterizing the chronic phase. However, conservative treatment options are limited and there is currently no standard non-surgical therapy. Non-surgical therapies have included oral antioxidant agents (i.e., vitamin E, potassium aminobenzoate) or intralesional injections of corticosteroids, collagenase, or verapamil. Surgical treatment focuses on excision of the plaque; the “Nesbit” procedure involves excision of the plaque accompanied by patch grafting of the defect left by the excision. Recently, there has been interest in extracorporeal shock wave therapy (ESWT) as a treatment of Peyronie’s disease. While ESWT is a standard urological therapy to disintegrate kidney stones, the mechanism of action is unknown in Peyronie’s disease, where the plaques may or may not be calcified.

POSITION STATEMENT:

Extracorporeal shock wave therapy (ESWT) is considered experimental or investigational, as there is insufficient clinical evidence to support the use of ESWT as a treatment of Peyronie’s disease. There is minimal published scientific literature and controlled trials. The overall poor quality of the literature and the lack of scientific data do not permit conclusions regarding the safety and efficacy of this therapy.

BILLING/CODING INFORMATION:

HCPCS Coding:

There is no specific CPT or HCPCS code that describes this procedure.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Fibrosis: the formation of fibrous tissue.

Plaque: a localized abnormal patch on a body part or surface and especially on the skin.

Tunica albuginea: the dense, white, inelastic tissue immediately covering the testis.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. Akin-Olugbade Y, Mulhall JP, The Medical Management of Peyronie’s Disease, Nat Clin Pract Urol. 2007 Feb; 4(2): 95-103.
  2. American Urological Association, AUA Guideline on the Management of Erectile Dysfunction: Diagnosis and Treatment Recommendations, 2005, accessed at auanet.org 10/26/09.
  3. Blue Cross Blue Shield Association Medical Policy. 2.01.62. “Extracorporeal Shock Wave Therapy in the Treatment of Peyronie’s Disease”, 04/08.
  4. Dohle G. Peyronie's disease: Can we prevent disease progression? Eur Urol. 2006 Jun; 49(6): 946-7.
  5. Hauck EW, Diemer T, Schmelz HU, Weidner W. A critical analysis of nonsurgical treatment of Peyronie's disease. Eur Urol. 2006 Jun; 49(6): 987-97.
  6. Lebret T, Loison G, Herve JM, Mc Eleny KR, Lugagne PM, Yonneau L, Orsoni JL, Saporta F, Butreau M, Botto H. Extracorporeal shock wave therapy in the treatment of Peyronie's disease: experience with standard lithotriptor (siemens-multiline). Urology. 2002 May; 59(5): 657-61.
  7. Manikandan R, Islam W, Srinivasan V, Evans CM. Evaluation of extracorporeal shock wave therapy in Peyronie's disease. Urology. 2002 Nov; 60(5): 795-9; discussion 799-800.
  8. National Institute for Clinical Excellence. Extracorporeal shockwave therapy for Peyronie's disease. London: National Institute for Clinical Excellence (NICE), 2003:2.
  9. Poulakis V, Skriapas K, de Vries R, et. al, Extracorporeal Shockwave Therapy for Peyronie’s Disease: An Alternative Treatment?, Asian J Androl. 2006 May; 8(3): 361-6.
  10. Srirangam SJ, Manikandan R, Hussain J, Collins GN, O’Reilly PH, Long-Term Results of Extracorporeal Shockwave Therapy for Peyronie’s Disease, Endourol. 2006 Nov; 20(11): 880-4.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 12/03/09.

GUIDELINE UPDATE INFORMATION:

03/15/04

New Medical Coverage Guideline.

03/15/05

Scheduled review and revision of guideline consisting of updating references and maintaining investigational status.

03/15/06

Annual review; G0280 removed. Continue investigational.

03/15/07

Scheduled review and revision of guideline consisting of updated references.

06/15/07

Reformatted guideline.

02/15/08

Annual review: investigational status maintained, and updated references.

02/15/09

Annual review: investigational status maintained, and updated references.

12/15/09

Annual review: investigational status maintained, and updated references.

05/11/14

Revision: Program Exceptions section updated.

Date Printed: June 25, 2017: 01:19 PM