Erectile Dysfunction and Peyronie's disease — CPB 0007 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0007 — its erectile dysfunction and Peyronie's disease coverage policy — effective March 7, 2026. Here's what billing teams need to know before submitting claims.

This update to the Aetna erectile dysfunction coverage policy touches a wide range of CPT codes, from diagnostic labs and duplex scans (CPT 93980, 93981) to penile prosthesis procedures (CPT 54400–54417) and Peyronie's disease excision (CPT 54110–54112). CPB 0007 Aetna governs both medical necessity determinations and the line between covered and experimental treatment. The policy is detailed and the exclusion list is long — get your charge capture aligned before claims start hitting.

Quick-Reference Table

Aetna Erectile Dysfunction Coverage Criteria and Medical Necessity Requirements 2026

The Aetna erectile dysfunction coverage policy sets specific thresholds for what gets paid. Aetna considers both diagnosis and treatment medically necessary — but only when you meet the criteria exactly. Vague documentation won't get it done.

For diagnostic workup, covered services include a comprehensive history and physical with psychosocial evaluation, duplex scan (Doppler and ultrasound) with intracorporeal papaverine (CPT 93980, 93981), and pharmacological response testing using vasoactive drugs like papaverine HCl, phentolamine mesylate, or prostaglandin E1 (CPT 54235). Dynamic infusion cavernosometry and cavernosography (CPT 54231, 74445) are only covered for members headed to penile revascularization — and only if they also meet the revascularization medical necessity criteria separately.

Lab work has its own covered list. Blood glucose (CPT 82947), complete blood count (CPT 85025–85027), creatinine (CPT 82565), hepatic panel (CPT 80076), lipid panel (CPT 80061), PSA (CPT 84152–84154), serum testosterone (CPT 84402, 84403, 84410), thyroid function studies (CPT 84443, 84479, 78012), and urinalysis (CPT 81000–81003) are all covered when used for ED diagnosis. FSH, LH (CPT 83001, 83002), and prolactin (CPT 84146) are covered, but only if testosterone comes back below normal first. Don't bill pituitary workup labs without a documented low testosterone result — that's a straight claim denial.

Nocturnal penile tumescence testing has its own tiered coverage logic. Routine NPT testing — including postage stamp and snap gauge testing — is rarely covered. It's covered only when clinical evaluation can't distinguish psychogenic from organic impotence and any identified medical factors have already been corrected. RigiScan (a more advanced NPT device) is covered only when NPT is already indicated AND the simpler test results are equivocal or inconclusive. Document that stepwise process or the claim won't hold up.

For treatment, Aetna covers oral phosphodiesterase-5 (PDE-5) inhibitors, vacuum erection devices, and intracavernosal/intraurethral pharmacotherapy as first-line options. Penile prosthesis implantation (CPT 54400–54417) is covered after adequate trials of first-line treatments have failed. Penile revascularization (CPT 37788) requires the member to have arteriogenic ED, be under 55, have no evidence of generalized vascular disease, have no corporal veno-occlusive dysfunction, and be a non-smoker — or have ED caused by a focal arterial injury. That's a narrow gate. Make sure the clinical record documents all of it.

Aetna Erectile Dysfunction and Peyronie's Disease Exclusions and Non-Covered Indications

This section is where CPB 0007 gets complicated. The exclusion list is extensive. Aetna classifies the following as experimental, investigational, or unproven for ED diagnosis:

On the treatment side, several procedures carry a "not covered" designation. These include:

Bariatric surgery codes (CPT 43644, 43645, 43770–43775, 43845–43847) appear in the not-covered group for ED specifically. If your bariatric team is billing these for obesity-related ED — stop. That's not a covered indication under CPB 0007.

For Peyronie's disease, Aetna covers penile plaque excision (CPT 54110–54112) and injection procedures (CPT 54200–54205) under defined criteria. The source policy references 26 HCPCS codes, but the full HCPCS code list was not available in the data provided for this summary. For complete HCPCS code coverage details — including any drug codes for Peyronie's treatments — review the full CPB 0007 policy document at app.payerpolicy.org/p/aetna/0007. Extracorporeal shock wave therapy for Peyronie's is not covered. Intralesional verapamil is not covered. Intralesional interferon is not covered. Penile traction therapy — not covered. If you're billing any of those, expect denials.

Coverage Indications at a Glance

Aetna Erectile Dysfunction Billing Guidelines and Action Items 2026

CPT, HCPCS, and ICD-10 Codes for Erectile Dysfunction and Peyronie's Disease Under CPB 0007

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered / Experimental CPT Codes

HCPCS Codes

The source policy references 26 HCPCS codes. The full HCPCS code list was not available in the data provided for this summary. Review the complete CPB 0007 policy document at app.payerpolicy.org/p/aetna/0007 for the complete HCPCS code list, including any drug codes relevant to Peyronie's disease treatment.

Note: The policy data includes 38 additional CPT codes. Review the full CPB 0007 policy document at app.payerpolicy.org/p/aetna/0007 for the complete code list.