Insurance will not cover implants

The final frontier. Deciding when, if and how.

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needhelp
Posts: 202
Joined: Sun Jan 07, 2018 7:07 pm

Re: Insurance will not cover implants

Postby needhelp » Thu Feb 07, 2019 10:22 pm

Skier123 wrote:A few more thoughts on this thread, in no particular order:

1. Some people can and do "save up" for this procedure. Often the docs will discount their fees for private pay patients.
2. You may be better off financially buying health insurance on your own for a year, and declining your employer's coverage. (you don't want to have 2 "primary" insurance providers, then neither one will pay.) Many (most I think) Blue Cross / Blue shield plans that you can buy on the open market will cover the implant.
3. How much do you like your job? The economy is good right now and maybe its a good time for a job change to an employer who has better health insurance?
4. At the very least, make sure you read you current policy's exclusions with your own eyes. Insurance companies are notorious for discouraging the actual use of the insurance - so don't take anyone's word for it that this procedure is actually excluded until you read it yourself. (With a little digging, I was able to find the actual policy language on my insurance company's website.)
5. Although I have not looked into this myself ... there may be a supplimental health insurance plan that you could tack on to your employers coverage for a reasonable cost that would cover this procedure. It may be worth a call to a reputable insurance broker to find out.
5. Lastly, and I don't want to be too mean here - but all I can say is that once you get over these health-related speed bumps, your next girlfriend is going to be WAY better than your last one ... and you will be much better off in the long run.


Thank you for those encouraging words. I did look into another policy as a secondary. The problem I ran into is that this would be considered preexisting condition and no one would give me coverage. The only way you can get a preexisting condition covered is during open enrollment. They have to honor preexisting issues. I missed that window. I'm calling the insurance commissioner tomorrow and asking for help. Probably will get shot down. Yes my next thought is to try and move on. Really don't want to work for a bank (Wells Fargo) that could give a shit about guys ED issues. The other thought I had that was discussed with me by a close friend on FT is I'm looking to see if my policy will cover urgery for my peyronies? If they will fix my peyronies and then I get an implant why is that surgery categorized as an implant surgery which then is technically excluded. Half of the surgery should be covered????? Sound interesting but the way things are going it will probably get shot down too. And as fas as my old gf..... I really did not need to hear that today. I would have done anything in the world for her and all I asked was for some help with a ride because nobody knows this except me and her. No reason for her to tell me she met someone. She knows how this is killing me. That hurt. I hope I can get back dating again. Cant really do anything till I have my manhood back. And I hope I do meet someone that will be way better...… I wish I good have my life back.... seems like eternity . Thank you so much for your support. You've been great and thank you again
61 years old, single, Charlotte NC, Had a penile fracture. Implant scheduled for April 17. Dr Terlecki Winston-Salem, NC

Naples
Posts: 28
Joined: Mon Nov 06, 2017 3:30 pm

Re: Insurance will not cover implants

Postby Naples » Thu Feb 07, 2019 10:43 pm

My insurance company initially denied the claim as well. Stating it was in my exclusion in the policy. I asked for a copy of the language with the exclusion. And yes it was right there in the policy excluding penile prosthesis For erectile dysfunction when caused by other than organic disease. Even though the doctor explained the ED was caused from narrowing of blood vessels from diabetes they still denied it. I called them and talk to them about the language regarding the exclusion. The person I talked to said we did not realize that ED could be caused from an organic disease and that they would re-review the request. I didn’t hear a thing for several months so I called back and they actually told me they forgot and would get it reviewed. A couple weeks later I got a letter in the mail approving the procedure. I hope this helps make sure you look at the policy get eyes on the language .
54 ED, tried it all for last two years, was scheduled for titan implant Dec 11,2017. Insurance problems got approval finally. Implanted January 7, 2019, in Oklahoma City

needhelp
Posts: 202
Joined: Sun Jan 07, 2018 7:07 pm

Re: Insurance will not cover implants

Postby needhelp » Thu Feb 07, 2019 11:25 pm

Naples wrote:My insurance company initially denied the claim as well. Stating it was in my exclusion in the policy. I asked for a copy of the language with the exclusion. And yes it was right there in the policy excluding penile prosthesis For erectile dysfunction when caused by other than organic disease. Even though the doctor explained the ED was caused from narrowing of blood vessels from diabetes they still denied it. I called them and talk to them about the language regarding the exclusion. The person I talked to said we did not realize that ED could be caused from an organic disease and that they would re-review the request. I didn’t hear a thing for several months so I called back and they actually told me they forgot and would get it reviewed. A couple weeks later I got a letter in the mail approving the procedure. I hope this helps make sure you look at the policy get eyes on the language .


Yes....thank you. Good stuff. I'm going to review my policy and the language in the policy first thing tomorrow. Thank you for your support
61 years old, single, Charlotte NC, Had a penile fracture. Implant scheduled for April 17. Dr Terlecki Winston-Salem, NC

needhelp
Posts: 202
Joined: Sun Jan 07, 2018 7:07 pm

Re: Insurance will not cover implants

Postby needhelp » Fri Feb 08, 2019 10:27 am

needhelp wrote:
Naples wrote:My insurance company initially denied the claim as well. Stating it was in my exclusion in the policy. I asked for a copy of the language with the exclusion. And yes it was right there in the policy excluding penile prosthesis For erectile dysfunction when caused by other than organic disease. Even though the doctor explained the ED was caused from narrowing of blood vessels from diabetes they still denied it. I called them and talk to them about the language regarding the exclusion. The person I talked to said we did not realize that ED could be caused from an organic disease and that they would re-review the request. I didn’t hear a thing for several months so I called back and they actually told me they forgot and would get it reviewed. A couple weeks later I got a letter in the mail approving the procedure. I hope this helps make sure you look at the policy get eyes on the language .


Yes....thank you. Good stuff. I'm going to review my policy and the language in the policy first thing tomorrow. Thank you for your support


I pulled up a copy of my benefits. this is what the "exclusion title says" ......
"in addition to any exclusion's, limitations or services listed as not covered as specified in this chapter the medical plans DO NOT cover or pay for the following:
Penile implants or sexual dysfunction devises, except for gender reassignment surgery...
Not sure where else to look. You need to be an attorney to read this. Is there something else I should be looking for?
61 years old, single, Charlotte NC, Had a penile fracture. Implant scheduled for April 17. Dr Terlecki Winston-Salem, NC

Lost Sheep
Posts: 2637
Joined: Mon Jul 04, 2016 11:16 pm

Re: Insurance will not cover implants

Postby Lost Sheep » Fri Feb 08, 2019 12:53 pm

needhelp wrote:
whostosay wrote:
needhelp wrote:
Our systems were down today. I will look at it tomorrow. They did say it was listed as an exclusion. I don't understand if its a medical issue and from the surgery that they paid for last year why wouldn't it be covered. The Dr was upset because he even said it was a medical issue. I'm going to call the insurance commissioner tomorrow and ask them for help. I'm praying they can help me. Im hoping they can make an exception

Certainly an option. Best of luck.


You've been in the business. Think there's a chance they could help?

If the disability (E.D.) was caused by a covered medical procedure, repair of the disability may be covered. Morally, if not legally.

The Doctor and his staff may be able to help with the appeal by writing justification, etc.

Last resort: If they cover penile implant for sex-change, NOT covering implant for restoration might be gender discrimination. The exclusion may be invalid by statute.
Lost Sheep
AMS LGX 18+3 Nov 6, 2017 Dr Shaw.
READ OLD THREADS to ask better questions and better understand answers.
Make yourself part of your medical team.
Document your current penile size: photos and written records.
Pre-op V.E.D. therapy helps.

needhelp
Posts: 202
Joined: Sun Jan 07, 2018 7:07 pm

Re: Insurance will not cover implants

Postby needhelp » Fri Feb 08, 2019 1:25 pm

Lost Sheep wrote:
needhelp wrote:
whostosay wrote: Certainly an option. Best of luck.


You've been in the business. Think there's a chance they could help?

If the disability (E.D.) was caused by a covered medical procedure, repair of the disability may be covered. Morally, if not legally.

The Doctor and his staff may be able to help with the appeal by writing justification, etc.

Last resort: If they cover penile implant for sex-change, NOT covering implant for restoration might be gender discrimination. The exclusion may be invalid by statute.


Thanks Lost Sheep. I called the confidential company hotline today. Gentleman was nice on the phone. He is going to look into options for me. I asked why they could not make an exception for a medical issue that is requested by the dr. If this wasn't such a private matter Id take it to social medial and blast the hell out of wells Fargo! let it go viral...they already have a black eye with the public. I told him maybe I should have a sex change....that is soooo wrong to accept that but not a medically needed issue. He said to file a complaint with my insurance company (Anthem B&B) Filing it under discrimination reasons. He wanted to know how I was doing emotionally....really????? I said if Wells Fargo really cared they wouldn't be putting me through this shit. He agreed. He asked if it was affecting me at work....really???? my dick is worthless, cant have a relationship, cant fuck, I have a limp noodle....but other than that, I'm so fucken happy I cant stand it!! I said yes ,its affecting me at work! what options are they leaving me with... he is a councilor for the company. I figured I get noticed and heard more with someone like that. He said there is also a grant that may be available for financial issues. I appreciate every body's support and helping me with the fight.....we have some great guys on this site....thank you to all of you!!
61 years old, single, Charlotte NC, Had a penile fracture. Implant scheduled for April 17. Dr Terlecki Winston-Salem, NC

needhelp
Posts: 202
Joined: Sun Jan 07, 2018 7:07 pm

Re: Insurance will not cover implants

Postby needhelp » Fri Feb 08, 2019 4:31 pm

sorry for the bad spelling .....
61 years old, single, Charlotte NC, Had a penile fracture. Implant scheduled for April 17. Dr Terlecki Winston-Salem, NC

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handfulWES
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Re: Insurance will not cover implants

Postby handfulWES » Fri Feb 08, 2019 7:57 pm

I found the spelling fine as I understood every word. I have continued to rack my brain on this as I have had my own fights with the insurance namely Anthem B&B. I had a 6 months fight to get the AMS 700 when what they opted to pay for was junk. The reason for my 3rd revision. I had 2 implants, lesser models from AMS and I was denied the 700 because of $900.00 in cost. Six fucking months I fought and my doctor fought almost everyday. They got tired of the letters and phone calls caved in and give me the 700 which was 1992.

If I remember right there was a CAP on expenses for the implant its self. I was nice, FIRM and then JUST FUCKING UGLY - That one did the trick. I told them I would haul their fucking asses to court and I didn't fucking care if the whole world knew I needed an implant. I didn't go to court nor hire an attorney. I did get their attention. In VA they were being hit on all sides concerning coverage. They didn't need another black eye out in the public. Worked like a charm.

WES
68, single, have had an implant since I was 42. Goals: to help men with ED; help men over come years of failure; to know their bodies; have a richer fuller sex life whether they or straight, Bi or gay. last I traveled this road starting in the late 60's

Lost Sheep
Posts: 2637
Joined: Mon Jul 04, 2016 11:16 pm

Re: Insurance will not cover implants

Postby Lost Sheep » Fri Feb 08, 2019 8:05 pm

needhelp wrote:The other thought I had that was discussed with me by a close friend on FT is I'm looking to see if my policy will cover urgery for my peyronies? If they will fix my peyronies and then I get an implant why is that surgery categorized as an implant surgery which then is technically excluded.

I just re-read this post where you mentioned that you have Peyronie's Disease. I missed that before. If the implant is solely for fixing the Peyronie's, then it is NOT EXCLUDED by the language you cited before (implant for treatment of E.D.)

Is that a vehicle for getting coverage? Your surgeon might be willing to write a letter to that effect.

needhelp wrote: I pulled up a copy of my benefits. this is what the "exclusion title says" ......
"in addition to any exclusion's, limitations or services listed as not covered as specified in this chapter the medical plans DO NOT cover or pay for the following:
Penile implants or sexual dysfunction devises, except for gender reassignment surgery...
Not sure where else to look. You need to be an attorney to read this. Is there something else I should be looking for?

Insurance policies (as far as I know, which is not very far, I admit) cannot tell physicians what treatments to apply to any particular disease as long as they are FDA approved, etc.

I think you have several points you can make to your insurance company. If they think you will not go away, they may just authorize coverage to get you off their back. (Sad that that statement can be true.)
Lost Sheep
AMS LGX 18+3 Nov 6, 2017 Dr Shaw.
READ OLD THREADS to ask better questions and better understand answers.
Make yourself part of your medical team.
Document your current penile size: photos and written records.
Pre-op V.E.D. therapy helps.

needhelp
Posts: 202
Joined: Sun Jan 07, 2018 7:07 pm

Re: Insurance will not cover implants

Postby needhelp » Fri Feb 08, 2019 9:43 pm

Lost Sheep wrote:
needhelp wrote:The other thought I had that was discussed with me by a close friend on FT is I'm looking to see if my policy will cover urgery for my peyronies? If they will fix my peyronies and then I get an implant why is that surgery categorized as an implant surgery which then is technically excluded.

I just re-read this post where you mentioned that you have Peyronie's Disease. I missed that before. If the implant is solely for fixing the Peyronie's, then it is NOT EXCLUDED by the language you cited before (implant for treatment of E.D.)

Is that a vehicle for getting coverage? Your surgeon might be willing to write a letter to that effect.

needhelp wrote: I pulled up a copy of my benefits. this is what the "exclusion title says" ......
"in addition to any exclusion's, limitations or services listed as not covered as specified in this chapter the medical plans DO NOT cover or pay for the following:
Penile implants or sexual dysfunction devises, except for gender reassignment surgery...
Not sure where else to look. You need to be an attorney to read this. Is there something else I should be looking for?


Insurance policies (as far as I know, which is not very far, I admit) cannot tell physicians what treatments to apply to any particular disease as long as they are FDA approved, etc.

I think you have several points you can make to your insurance company. If they think you will not go away, they may just authorize coverage to get you off their back. (Sad that that statement can be true.)


My surgeon is out of the country till 2/19...I'll check back with him then. Im visiting another surgeon 3/19. Supose to very good to. His discount for pay out of pocket is alot more. Just prepairing myself incase I have to go that route.
Im going to send in an appeal regarding the exclusion ….to more people. I'll have to explain my situation again. I just feel uncomfortable explaining my situation. I'm trying to keep it as priviate as possible.
61 years old, single, Charlotte NC, Had a penile fracture. Implant scheduled for April 17. Dr Terlecki Winston-Salem, NC


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