New to this site - Ed is like hell on earth to me. - need implant, have questions

[nowimready]

Hello Gentlemen. i am a 56 year old man who is physically healthy. I have been silently suffering with ED for the past 7 years now. My wife left me because of it & I can't stay in a relationship. I think one of the worse feeling is to want to be in a relationship but cant because you cant perform you manly duties. Women start off understanding & are open to alternative methods but in the long run the find a excuse to get out of the relationship. I have tried everything from all kinds of pills to the sonic wave. The pump & trimix work but are not adequate to a long term resolution. I live in the Miami area & have decided to get a implant. So far I have been thwarted in my efforts. What I am asking for from this sites is some basic information to allow me to schedule & have the surgery performed. I need help is these issues
1)Primarily I need to know some specific insurance plans that cover the surgery, the doctors cost & the device ( with no deductibles'). This is my primary stumbling block. I have called several doctors & nobody can give me a specific answer. If someone has an answer to this or can point me in the direction to get this information I would greatly appreciate it, then I can purchase said insurance & get the ball rolling. ( I can not afford to pay for the operation & device out of pocket)
2) If someone could tell me the prerequisites that must be completed prior to approval i'm sure I can have my urologist supply said information to the doctors when needed, like I said I have tried everything to no avail
3) If someone could refer me to a doctor or medical facility that could perform the surgery I would greatly appreciate it.
I look forward to you responses. --- Thank you

[tomas1]

I realize it's easy for me to say, but I think you should somehow pay for the procedure.
I hated fucking with insurance companies (still do). I'd guess they would stonewall you and you'd end up waiting for Medicare. There will be too many good times and relationships that you'll fail to enjoy until it's too late.

[stephen54]

There are literally thousands of versions of just Blue Cross/Blue Shield plans. Thousands. Each with extremely different and specific inclusions and exclusions. Plan provisions vary by employer menu of services agreed to be covered, etc. If you're thinking of buying a plan, solo, on the open market, then I think you've got to bang the phone and internet and very specifically ask the questions - what, specifically, is or is not covered.

I'm sorry for what you're going through. It's obviously horrible.

You need to do your homework and really get up to speed on the relevant medical/billing coding in order to ask the right questions of insurers. CPT Codes:

CPT 54405 (Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders and reservoir) is the most common billing code you will encounter with implantation. Ask with specificity when you call or email plans for details.

ICD 10 Codes - these are diagnostic codes which describe the underlying reason for surgeries. Different insurance plans will require different ICD 10 codes to get you covered for an allowable surgery.

No one can tell you the prerequisites, because each plan is going to be different. Again - thousands of plans with thousands of unique requirements for either inclusion or exclusion of your claim.

Typically? You may see a plan want a documented failure of oral therapies (Viagra etc) and then a documented failure of injectables (Trimix etc) for x period of time, with whatever incremental dosing titrations having failed over y amount of time period, etc etc etc.

You have a lot of homework to do. But it's workable. Most of this is easily searchable online. Where it's not...swallow your embarrassment and start dialing.

Doctor or facility? - there's plenty. But I would strongly advise you to not go to the first surgeon because they're either geographically convenient or because their price is cheaper. I won't eat "Discount Sushi". Same concept here, only with much more devastating, dire consequences if you seek out implantation based largely on a favorably cheaper price. This is not the way to go about this. My serious advice is - find the best surgeon you can, and find a way to make it happen with that surgeon. Nothing but regrets and dark days for you later if you compromise on the skill of the guy with the knife in his hand.

I'm a healthcare exec and very familiar with some of your obstacles you're worried about here - please feel free to message me privately if I can be of any help. Chin up, man. Seriously. I know shit looks bleak now, but there is a way forward.

[newbie443]

Hello Gentlemen. i am a 56 year old man who is physically healthy. I have been silently suffering with ED for the past 7 years now. My wife left me because of it & I can't stay in a relationship. I think one of the worse feeling is to want to be in a relationship but cant because you cant perform you manly duties. Women start off understanding & are open to alternative methods but in the long run the find a excuse to get out of the relationship. I have tried everything from all kinds of pills to the sonic wave. The pump & trimix work but are not adequate to a long term resolution. I live in the Miami area & have decided to get a implant. So far I have been thwarted in my efforts. What I am asking for from this sites is some basic information to allow me to schedule & have the surgery performed. I need help is these issues
1)Primarily I need to know some specific insurance plans that cover the surgery, the doctors cost & the device ( with no deductibles'). This is my primary stumbling block. I have called several doctors & nobody can give me a specific answer. If someone has an answer to this or can point me in the direction to get this information I would greatly appreciate it, then I can purchase said insurance & get the ball rolling. ( I can not afford to pay for the operation & device out of pocket)
2) If someone could tell me the prerequisites that must be completed prior to approval i'm sure I can have my urologist supply said information to the doctors when needed, like I said I have tried everything to no avail
3) If someone could refer me to a doctor or medical facility that could perform the surgery I would greatly appreciate it.
I look forward to you responses. --- Thank you

Do you have insurance now with an employer that has an exclusion? If so you need to take note of the cost to you for the insurance. Marketplace plans do have coverage for this. But they are expensive and they get to choose who you go to for this. My experience is the insurance companies do not like to pay for these devices. Medicare seems to be an exception or other federal and some local government jobs. My marketplace bcbs gold plan was over $1200 a month and did not cover all the cost of the surgery and I could only go to low volume doctors who had history of poor results. The surgery would have cost me 7k plus the monthly cost of the insurance. So about 21.4k. Yours may be more or less but you can subtract what what you pay now a year for insurance from that. You can sign in to your states marketplace and see what it would cost you for insurance and what deductibles and max out of pocket would be. Insurance for me covered for physical injury or illness. And medications both oral and injectable had to fail. And of course there was prior approval needed before hand so insurance could drag this into the next year.

So options are if you have current insurance to contest it for coverage. Buy market place insurance. See about a government job or other that has coverage. Or do self pay. There are threads on self pay costs for doctors if you search for them. And there is surgeo self pay medical procedures. Surgeo plans also include a 3rd party insurance plan if you have problems with the first surgery for the first year.

Best of luck to you with this.

[Txagq8]

I guess the first question is what insurance do you currently have, and will they pay for a CPT code of 54405? If so, you’re in pretty good shape. If not, you might very well be better off going self pay. By the time you’ve paid the high premiums of whatever Cadillac plan you’ve had to buy to get an implant, you might have spent as much as you would have just getting it done.

I concur with the poster who cautioned against grabbing first cheap doc you can find. I would add that there are good, reputable, high volume implant guys who offer surgical packages for the self pay folks. Not sure about Florida but just up the road in Atlanta you have Dr. Hakky with a pretty good reputation on here. There are a couple of doctors (including mine) in Texas and I know there are others scattered nationwide. I’m sure things have gone up (they always do) but you are probably looking at a total self pay of 17K to the low 20s.

This is going to boil down to your insurance, what it covers. What it excludes. Now that you need an implant, it’s gonna be pretty damned tough to find coverage that pays for one if you don’t have one.

Some insurance carriers exclude an implant but will entertain appeals to that exclusion. I know of a couple of guys who successfully worked that and got their plan to pay for it.

Like the other guys, I wish you good luck.

[mschicago]

I have Anthem Blue Cross Blue Shield. I was on my wife’s plan (Aetna) until her death last year. I used the pills to no avail. I won’t put a needle Lon my sick so an implant was the only choice. Completely impotent anyway.

Since I had to start fresh with no history with Anthem, I researched and learned I needed to show that I had tried the pills or shots first for 6 months. I got my doctor to give my lowest level of Viagra in January and then had him up the prescription to a higher prescription level in March. I waited until I got through 6 months, made an appointment for a top implant surgeon in early August and set surgery for late October 2022.

I received notification from Anthem last week they will cover the surgery. I am sure it’s because I had the 6 month history they required.

Good luck!

[Old Guy]

Sorry for your issues and the results it caused. ED is Hell.
First off, if you don't have insurance purchasing a plan now will more than likely have limitations. They probably won't pay for a big surgery the day after you buy in. Usually, they'll make you wait a year or two.
As far as prerequisites, insurance will need a diagnosis of your physical problem. They will probably also want to see what treatments you've tried and have failed. If pills or injections still work, they are hesitant to pay for the implant.
The sad part is they won't give a damn about your personal life, divorced because of it or can't keep a relationship.
Even with insurance my co-pay was $3,600. The only way I know implant surgery is free is if you have an insurance plan and Medicare Part B.

[nowimready]

I would like to thank each of you who responded to my inquiry's. You have supplied me with more valuable information than any doctor that has ever given me. I now have so footwork to do and much more to think about.

[archway]

Hi there. I live in Atlanta and called Dr.Eid’s office in NY eight years ago. Scheduled a phone consult (I paid for that). Then I was out in contact with Dr. Eid’s office staff and they reviewed my insurance, total cost, and my out of pocket. I had United HealthCare PPO and ended up paying $4500 out of pocket. They worked with my on scheduling, hotel stay in NY. Top notch service. All insurance plans are different, so I recommend taking the guess work out of the equation and just pick up the phone and call Dr. Eid at Advanced Urological Care NY NY. He’s the best and I think you’ve already made up your mind. Good luck.
Archway

[RayChez]

What are you waiting for? I had an implant when I was around 58 because of prostrate cancer. The best thing they could have ever invented for men who are suffering from ED. I feel as normal as a man could with the implant. I love it and you will to.