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Coverage criteria policies

Sex therapy, sexual dysfunctions and paraphilic disorders

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for sex therapy, sexual dysfunctions, and paraphilic disorders.

Coverage

Coverage for sexual dysfunctions and sex therapy (Individual or couples psychotherapy services to treat sexual dysfunction or to enhance sexual pleasure, intimacy or relationship enhancement.) is generally excluded in your member contract and, therefore, not covered.

Treatment for the following diagnoses listed under Indications that are covered can be covered when treatment is both medically necessary and authorized by the HealthPartners Behavioral Health department.

Indications that are covered

Paraphilic Disorders:
  1. Exhibitionistic Disorder - F65.2
  2. Fetishistic Disorder - F65.0
  3. Frotteuristic Disorder - F65.81
  4. Pedophilic Disorder - F65.4
  5. Sexual Masochism Disorder - F65.51
  6. Sexual Sadism Disorder - F65.52
  7. Transvestic Disorder - F65.1
  8. Voyeuristic Disorder - F65.3
  9. Other Specified Paraphilic Disorder - F65.89*
  10. Unspecified Paraphilic Disorder - F65.9*
    * (This diagnosis does not include compulsive sexual behavior (CSB) as CSB is comprised of non-paraphilic behaviors).
Compulsive Sexual Behavior
  1. Other Specified Disruptive, Impulse-Control and Conduct Disorder – Hypersexual - F91.8
Gender Dysphoria:
  1. Transsexualism – F64.0
  2. Dual Role Transvestism- F64.1
  3. Gender Dysphoria in Children - F64.2
  4. Other Specified Gender Dysphoria - F64.8
  5. Unspecified Gender Dysphoria - F64.9
Child Sexual Abuse:
  1. Confirmed – Initial Encounter - T74.22XA
  2. Confirmed – Subsequent Encounter - T74.22XD
  3. Confirmed - Sequela – T74.22XS
  4. Suspected - Initial Encounter - T76.22XA
  5. Suspected - Subsequent Encounter - T76.22XD
  6. Suspected – Sequela-T76.22XS
Other Circumstances Related to Child Sexual Abuse:
  1. Encounter for mental health services for victim of child sexual abuse by parent - Z69.010
  2. Encounter for mental health services for victim of child non-parental sexual abuse - Z69.020
  3. Personal history (past history) of child sexual abuse in childhood - Z62.810
  4. Encounter for mental health services for perpetrator of parental child sexual abuse - Z69.011
  5. Encounter for mental health services for perpetrator of non-parental child sexual abuse - Z69.021
Spouse or Partner Violence, Sexual:
  1. Confirmed – Initial Encounter - T74.21XA
  2. Confirmed – Subsequent Encounter - T74.21XD
  3. Confirmed – Sequela – T74.21XS
  4. Suspected - Initial Encounter - T76.21XA
  5. Suspected - Subsequent Encounter - T76.21XD
  6. Suspected – Sequela – T76.21XS
Other Circumstances Related to Spouse or Partner Violence, Sexual:
  1. Encounter for mental health services for victim of spouse or partner violence, sexual - Z69.81
  2. Personal history (past history) of spouse or partner violence, sexual - Z91.410
  3. Encounter for mental health services for perpetrator of spouse or partner violence, sexual Z69.82

Indications that are not covered

Sexual Dysfunctions
  1. Delayed Ejaculation - F52.32
  2. Erectile Disorder - F52.21
  3. Female Orgasmic Disorder F52.31
  4. Female Sexual Interest / Arousal Disorder - F52.22
  5. Genito-Pelvic Pain / Penetration Disorder - F52.6
  6. Male Hypoactive Sexual Desire Disorder - F52.0
  7. Premature (Early) Ejaculation - F52.4
  8. Other Specified Sexual Dysfunction - F52.8
  9. Unspecified Sexual Dysfunction - F52.9
  10. Substance/Medication-Induced Sexual Dysfunction

Definitions

Sex Therapy – Individual or couples psychotherapy services to treat sexual dysfunction or to enhance sexual pleasure, intimacy or relationship enhancement.

Paraphilia – a paraphilia is a pattern of recurring sexually arousing mental imagery or behavior that involves unusual and especially socially unacceptable sexual practices (such as sadism or pedophilia). The presence of a paraphilia by itself does not automatically justify or require clinical intervention.

Paraphilic Behaviors – refers to behaviors that are considered to be outside of the conventional range of sexual behaviors (e.g. exhibitionism, voyeurism, pedophilia, sexual masochism, sexual sadism, transvestic fetishism, fetishism and frotteurism.

Non-paraphilic Behaviors – represent engagement in commonly available sexual practices such as attending strip clubs, compulsive masturbation, paying for sex, excessive use of pornography and repeated engagement of extra-marital affairs (e.g., compulsive sexual behavior).

Paraphilic Disorder – when a paraphilia is currently causing distress or impairment to the individual, or a paraphilia whose satisfaction has entailed personal harm or risk of harm to others.

Sexual Dysfunction – Disorders that are typically characterized by a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure.

Codes

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

    Codes

    Description

    90785

    Interactive complexity

    90832

    Psychotherapy, 30 minutes with patient

    90834

    Psychotherapy - PT/Fam, 45 mins

    90837

    Psychotherapy - PT/Fam, 60 mins

    90846

    Family psychotherapy (without the patient present)

    90847

    Family psychotherapy (conjoint psychotherapy) (with patient present)

    90849

    Multiple-family group psychotherapy

    90853

    Group psychotherapy (other than of a multiple-family group)

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the American Psychiatric Association's (APA) classification and diagnostic tool.

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Policy activity

  • 05/03/2011 - Date of origin
  • 09/21/2018 - Effective date
Review date
  • 09/2018

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