Introduction and implant info

[drjeeps]

Sorry for the confusion - yes, it is covered for a sex change, not for a man with a physiological issue such as prostate cancer.

The doc did the peer meeting today and "politely screamed" at the insurance doc. Being only 52, he told them that they could either solve the issue correctly or deal with 30 years of clinical depression treatment. I think my doc is awesome. Whatever he said, it has now been escalated to the next level, the doc is pretty sure they are going to approve it, and I got a call from the insurance company by one of their health advocates to walk me through this process. Interesting...

More to come.

[oldbeek]

Your insurance should pay. There is no way to justify their position. It discriminates by gender. I had peyronies from scar tissue and the LGX straightened it up. Lots of luck.

[Lost Sheep]

Sometimes it is just a matter of using the proper numerical code on a form.

Bureauracracy...sigh,

The insurance rep should be able to get it done. Just make sure you get him on your side.

Politics...sigh.

[David_R]

Sometimes if the insurance company covers breast reconstruction after a mastectomy -- which is a non-life-threatening condition that affects one's quality of life -- they can be pressured into also covering a penile implant (for which E.D. is also a non-life-threatening condition that affects one's quality of life).

I do have to share, however, that my implant was covered 17 years ago, insurance told me, because it was the result of a medical physical condition (it was post-prostatectomy). But if it was needed because of a psychological (meaning non-physical) condition, they told me, it would not have been covered. (sigh)

[drjeeps]

So, I got another rejection today from Cigna. I'm now sending it to their "Level 2" . What a crock of bull.

This is a copy of my letter I'd sent - note the formatting is goofed due to the HTML here and I've redacted the company I work for to protect the guilty...

Re: Customer Appeal Request

I am a Prostate Cancer survivor. I was diagnosed in 2015 at age 48 with a Gleason 3+4=7 and biopsy samples proved to be cancerous. I routinely had my PSA checked in conjunction with digital inspection beginning in my 40’s due to my dad having prostate cancer at 61 and wanting to be proactive about my health.

After discussion, medical opinions, and research - my wife I and I elected for surgery. I was aware of the common research and findings showing that a percentage of survivors suffered at least temporary Erectile Dysfunction (ED), however, as I was young, in very good shape, and with no prior history of ED it was expected that I would recover sexual function.

I had a nerve-sparing prostectomy performed via the da Vinci robotic method at age 49 (September 2016) and I'm 52 now. At 34 months post-operation, I have complete Erectile Dysfunction. Pills, such as Viagra and Cialis have zero effect at any dosage. I had some success with Tri-Mix and Bi-Mix injections; however they are problematic in their behavior and often result in pain during sex. Another side effect of the injections is that I have developed Peyronie’s Disease (PD) and now have a 20+ degree curvature of the penis and associated pain – further reducing the ability to have and enjoy of sexual intercourse.

My vascular function is very good (validated by my Urologist and tested via an ultrasound both while flaccid and with a bi-mix injection) and my nerves were spared during the prostectomy - but I am unable to have any natural erections and am only able to have occasional erections via injection. At 34 months post-operation, I am well beyond the norm for recovery of functions. Further, the Peyronie’s Disease will need to be treated as any induced erections are painful and the curvature is increasing. Therefore, I wish to have a penile implant procedure performed. The implant is the only method available to properly resolve both issues.

My doctor (Daniel J. Mazur, MD Urology Associates Denver, CO) has submitted two requests to Cigna for coverage and been denied both times. These requests were submitted on 04/22/2019 and 05/09/2019. Since then, Dr. Mazur has attended two Peer-to-Peer meetings (on 07/08/2019 and 07/23/2019) with Cigna doctors and was informed that Cigna is denying this procedure.
 
Verbally, I have been told that this is a result of language in the XXX HDH Plan stating that the following are not covered: “*any medications, drugs, services or supplies for the treatment of male or female sexual dysfunction such as, but not limited to, treatment of erectile dysfunction (including penile implants), anorgasmy, and premature ejaculation”.

However, Page 73 of the XXX HIGH DEDUCTIBLE HEALTH PLAN states: “Reconstructive Procedures are services performed when the primary purpose of the procedure is either to treat a medical condition or to improve or restore physiologic function for an organ or body part. Reconstructive procedures include surgery or other procedures which are associated with an Injury, Sickness or Congenital Anomaly. The primary result of the procedure is not a changed or improved physical appearance.”

Further, please note on Page 34 under Gender Dysphoria that the following services are offered: HERE I INSERTED A PIC OF THE POLICY SHOWING A PHALLOPLASTY IS COVERED FOR A FEMALE.

According to the Mayo Clinic, a Phalloplasty requires an implant-type of device for the non-biological male to achieve an erection. The fact that this plan covers this for Gender Dysphoria and not for a biological male is blatant gender discrimination towards me as a biological male.

Please note that EEOC Compliance Manual, Chapter 3: Employee Benefits states:
The employer cannot provide different coverage to men and women where the risk insured against is mutually contractible - that is, where the underlying condition affects, or the treatment/test is available to, both men and women.

Where both men and women are, or could be, affected by the same condition or helped by the same treatment, the employer will be liable for sex discrimination if it provides different coverage to employees of each gender on the basis of gender.

This procedure is not for cosmetic purposes – it is to fix the Peyronie’s Disease and restore physiologic function to my penis. At 52 years old, I am struggling to see how this can be denied. Sexual intimacy is key ingredient of a loving relationship. Not being able to have this has greatly impacted my emotional state and relationship with my wife.

I am formally seeking an exception to the current plan’s coverage to allow me to have a penile implant procedure performed in order to correct Peyronie’s Disease as well as Erectile Dysfunction caused by an organic disease, Prostate Cancer.

I await your timely review of this matter and prompt response.

Sincerely,

[David_R]

Has your doctor's office gone to bat for you? Sometimes they can point out that if they cover breast reconstruction after a mastectomy (because of cancer), they should also cover an implant after a prostatectomy (because of cancer). Otherwise this smacks of sexism. (Neither procedure is required to stay alive; both are to improve the quality of the patient's life after surgery.) Good luck, brother.

[drjeeps]

Denied for the second time. They are still stating that sexual dysfunction is not covered. Hilariously, they then state that neither male nor female are covered for that, including implants...yet they cover the sexual dysphoria change from female to male including that.

So, I've filed an official request for help from the ESBA (Employee Benefits Security Administration), which is the next step.

In the meantime, I've reached out to the HR department for help again, and have engaged our EAP program to talk with someone since this is really starting to affect everything.

[drjeeps]

ESBA (Employee Benefits Security Administration) stated:

ERISA regulates self-funded plans and the benefits provided in self-funded plans are not governed by the rules established for insurance companies. Since ERISA does not mandate any type of benefit coverage, plan sponsors are generally free to establish their own rules determining what benefits are offered, who is eligible for those benefits, and the level of benefits paid. The plan administrator or other appropriate plan official is responsible for interpreting those rules.

We have the Summary Plan Description (SPD) and despite other language regarding certain covered procedures, we would expect that the provision you cite would not be applicable to your situation since the Plan further provides for a denial of coverage for the treatment you are seeking. However, as evidenced above, the plan administrator ultimately interprets the coverage provisions provided in the SPD.

The Department is not able to mandate that a specific medical treatment be covered by the plan. The plan’s documents and rules define what is and is not considered a covered benefit. If a specific procedure or treatment is not covered by the plan, a plan amendment would be required to change the coverage limitations and allow a previously ineligible procedure to become a covered procedure.

Therefore, if you have not already done so, you may wish to request an official interpretation of the provision you cited and how it does or does not interact with the plan’s exclusionary provision specific to your situation and/or seek a change to the current Plan’s provisions.

We regret that we could not provide a more favorable response to your complaint.

AWESOME! I'm now left hoping to make inroads with my HR department. Pissed does NOT describe my mood...

[alibaba]

Similar age, 50 when I had the surgery except no family history, 12/16 positive biopsy ( 100% involvement including nerves upon surgery) and P.S.A. going up 3/4 point every 2 weeks. Similar experience with insurance. Call the Boston Scientific help line. PROPER CODING of your prostate cancer and E.D. will often get your coverage. It took me 2 years to learn that and succeed. The help line knows the proper codes that it seems many doctors seldom get done right. Most hospitals and doctors want "pre-approval". I have United Healthcare. They do not pre-approve, but will tell if it is covered or not. In the end, I had to battle with the hospital to get it through their head that it was covered, but they had to do it and send the bill to get it 'approved". A couple hospitals wanted a $30,000 cash or bank letter of guarantee because the insurance company did not pre-approve. All bullshit from the "we want our money or else" people. Covered expense should equate to approval as long as the charges are reasonable and a contracted insurance company.

[MK1965]

I had and still have Aetna Insurance thru my employer.
My implant last September was covered by Aetna and it cost me $1450 out of pocket because max out of pocket was not reached.
Here is how it ways coded by my doc and submitted to Insurance company:

CPT code 54405 - insertion of multi component penile prosthesis including placement of pump, cylinders and reservoir.

ICD 10 Diagnostic code : Z85.46 - Personal history of malignant neoplasm of prostate.

MK