Aetna Guideline - Erectile Dysfunction & Hypogonadism Workup
Aetna POC Policy Set · effective 2026-01-01 · version v1
Metadata
Doc IDguideline::aetna::ed_hypogonadism_v1
PayerAetna
Payer Slugaetna
Topiced hypogonadism
Document Typepayer_guideline
Chunks5
Covered ICD Codes (10)
N52.9
N52.1
N52.02
N52.31
E29.1
E34.9
R68.82
R79.89
N50.819
N50.82
Procedure Keywords (7)
testosterone replacement therapy
PDE5 inhibitor therapy
penile Doppler ultrasound
intracavernosal injection therapy
penile prosthesis implantation
testosterone level testing
endocrine workup
Guideline Chunks (5)
Each chunk has its own embedding and is independently retrievable
guideline::aetna::ed_hypogonadism_v1#chunk0
Diagnostic workup and treatment for erectile dysfunction (ED) and hypogonadism may be considered medically necessary when symptoms persist despite first-line management and when laboratory or vascular workup is indicated.
guideline::aetna::ed_hypogonadism_v1#chunk1
1. Erectile dysfunction (ICD N52.9, N52.1) with documented duration of three months or more.
2. ED associated with vasculopathy (ICD N52.9) in patients with cardiovascular risk factors.
3. Corporo-venous occlusive ED (ICD N52.02) requiring vascular workup.
4. ED following radical prostatectomy (ICD N52.31).
5. Male hypogonadism (ICD E29.1) with documented low testosterone on two morning samples.
6. Testosterone deficiency (ICD E34.9) with symptomatic confirmation.
7. Low libido (ICD R68.82) or low testosterone (ICD R79.89) with corroborating labs.
8. Testicular pain (ICD N50.819) or scrotum pain (ICD N50.82) requiring evaluation.
guideline::aetna::ed_hypogonadism_v1#chunk2
1. Two morning total testosterone measurements (preferred 8-10 AM, fasting).
2. Documentation of symptom duration and impact (IIEF score for ED cases).
3. Cardiovascular risk assessment.
4. Trial and response to first-line therapy (PDE5 inhibitors for ED).
5. Hematocrit, PSA, and lipid panel for testosterone replacement candidates.
6. Endocrine workup (LH, FSH, prolactin) for hypogonadism cases.
guideline::aetna::ed_hypogonadism_v1#chunk3
1. Single testosterone level without confirmatory repeat morning sample.
2. Missing IIEF score or symptom severity documentation.
3. Testosterone replacement requested without baseline PSA and hematocrit.
4. Penile prosthesis requested without trial of less invasive therapies.
5. Vascular workup requested without prior pharmacologic trial.
guideline::aetna::ed_hypogonadism_v1#chunk4
Likely eligible when symptom duration is at least three months, two confirmatory testosterone levels meet diagnostic threshold (for hypogonadism), prior pharmacologic therapy has been trialed, and baseline labs (PSA, hematocrit) are documented.
Manual review when only one testosterone level is available or when symptom documentation is incomplete.
Likely not eligible when first-line therapy has not been attempted or when laboratory criteria are not met.