Coverage

Medicare has a national coverage policy for the diagnosis and treatment of erectile dysfunction (ED), which includes the implantation of a penile prosthesis. Medicare coverage is further defined in most states by Local Coverage Decisions (LCDs).

Most commercial health insurers cover the medically necessary diagnosis and treatment of ED.

To avoid delays in payment or reimbursement, you should work with your physician's office and insurance carrier to verify coverage and insurance payment levels before beginning a treatment path.

Diagnostic Evaluation for Prior Approvals

All health care plans require that medical treatments be reasonable and medically necessary. To show this, health plans may require you to produce diagnostic evidence of organic impotence. The diagnostic work-up for ED can vary since the cause could be related to a vascular, neurogenic, psychogenic or endocrine problem.

Have you been denied coverage for a penile prosthesis?

What do you do next?

You have options...

Does my health plan cover penile prosthesis?

Can I obtain coverage from my health plan?

What are my options?

How do I write an appeal letter?

Perhaps you have been receiving treatments for months or even years. You may have gone through testing or other medical procedures before arriving at the decision to have a penile prosthesis implanted to restore your lifestyle. Now, you find out the insurance company has denied authorization for payment of the procedure.

Determine the type of denial:

• Is the denial based on a contract exclusion?

Review your benefit information for specific exclusion language. Some types of contract exclusions include no payment for:

• Sexual dysfunction
• Impotence
• Sexual inadequacy
• Penile prosthesis
• Penile implants

Review your benefit information for specific medical benefits such as:

• Prosthetic devices
• Reconstructive surgery
• Surgery to repair body function

You have the right to appeal any denial from your health plan. In many cases, there is a time limit following the denial in which your appeal must be received. Check your benefit information or any denial letter you received for specific timelines.

My insurance still won't pay. What can I do?

You have gone through the entire appeal process and your insurance still won't pay. If the contract language has a clearly written exclusion, your insurance may legally continue to deny coverage. What are your remaining options?

Review other medical policies you may have.

• Do you have Medicare?
• Are you covered under a secondary plan by someone else, such as a spouse?
• Have you served in the military and are covered under TriCare?
• Do you qualify under Cobra to be part of another plan?
• Is your health plan a self-funded program? Check with your Human Resource Department to determine whether you are covered under a self-funded program. Employers can make a final determination for coverage in self-funded plans. Request information on the process involved in having your request reviewed for coverage.

Explore the opportunity for open enrollment

• This usually occurs at year end and may allow you to choose another health plan.
• Determine whether another option is offered that may have benefits for erectile dysfunction and penile prostheses.
• Determine whether you are able to upgrade your current plan by paying extra premiums (These are referred to as riders).

Consider self payment

Paying for your surgery out-of-pocket may not be the most desirable option. It may be your only option if you have exhausted all other options. Here are considerations that could make self payment more feasible:

• Negotiate prices
• Explore all of your options regarding where you have your procedure performed. If your health plan is not paying for any of the costs, then you are not obligated to follow any rules set by the health plan. You would not be limited to facilities in network. You may research prices at different facilities and negotiate a price you are the most comfortable with.
• Utilize pre-tax flex spending plans.
• Explore loan options.

Call for assistance with exploring your options at: 1-888-865-3373.