Insurance will not cover implants

The final frontier. Deciding when, if and how.
Lost Sheep
Posts: 2139
Joined: Mon Jul 04, 2016 11:16 pm

Re: Insurance will not cover implants

Postby Lost Sheep » Tue Feb 12, 2019 9:28 pm

needhelp wrote: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.

I felt that way for many years (even after I figured out that I had E.D., which itself took a while). I finally mentioned it to my primary care physician and we tried Sildenafil Citrate (Viagra) and it worked, for a while. I got more comfortable discussing the situation with him and even with some of his nurses present (THAT was a hurdle!).

Eventually, I discussed my needs with non-medical personnel with the V.A. system in trying to arrange authorization, travel, lodging, etc.

I got used to explaining my situation. I am glad I did. A travel specialist, knowing my situation, clued me in to a Urological Surgeon who just got stationed at Elmendorf Air Force Base Hospital and he was GOOD. If I had not been so open about my situation, that networking would not have happened.
Lost Sheep
Born 1948 AMS LGX 18+3 implant Nov 6, 2017 by Dr Tavis Shaw. Spent 14 months researching in effort to optimize outcome. After 30 yrs of progressive unrecognized ED I will do this RIGHT; no second chance with one's first.
Anchorage AK, USA

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

Re: Insurance will not cover implants

Postby needhelp » Tue Feb 12, 2019 11:07 pm

Lost Sheep wrote:
needhelp wrote: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.

I felt that way for many years (even after I figured out that I had E.D., which itself took a while). I finally mentioned it to my primary care physician and we tried Sildenafil Citrate (Viagra) and it worked, for a while. I got more comfortable discussing the situation with him and even with some of his nurses present (THAT was a hurdle!).

Eventually, I discussed my needs with non-medical personnel with the V.A. system in trying to arrange authorization, travel, lodging, etc.

I got used to explaining my situation. I am glad I did. A travel specialist, knowing my situation, clued me in to a Urological Surgeon who just got stationed at Elmendorf Air Force Base Hospital and he was GOOD. If I had not been so open about my situation, that networking would not have happened.


Thanks Lost Sheep. Just an update on the insurance. They turned it down. They said they may change the exclution next year. I cant go this way for a year. There is a special "grant " that ee can apply for, for unexpected emergeny expences. This is my last hope. Trying to find a good surgeon now. The last one I liked, but I did not like his procedure if you have peyronies. Got an appt with another Dr who seems to be very good, but I found out he only uses AMS, no Titans. Im not saying I need or want a Titan but with peyronies I do not want to limit my options. There is another Dr who is excellent but he is hard to get into (long wait). Wish I could get this to all come together
61 years old, single, Charlotte NC, Had a penile fracture. Implant scheduled for April 17. Dr Terlecki Winston-Salem, NC

Lost Sheep
Posts: 2139
Joined: Mon Jul 04, 2016 11:16 pm

Re: Insurance will not cover implants

Postby Lost Sheep » Wed Feb 13, 2019 12:59 pm

needhelp wrote:Trying to find a good surgeon now.

I applaud your efforts to vet your surgeon's methodology. I passed on surgery at the V.A. in Seattle because I did not like the procedure they described. Though my medical opinion is virtually worthless, it is my penis and I wanted a different approach than they described.
needhelp wrote:They said they may change the exclution next year. I cant go this way for a year.

Speculating; this might be a way of putting you off, even though they may not have any such plans.
needhelp wrote: There is a special "grant " that ee can apply for, for unexpected emergeny expences. This is my last hope.

Again, speculating; this may be a way of appeasing you without setting a precedent of covering an expensive procedure. They could let you have the implant but not obligate themselves to do it for anyone else. Make sure the grant covers everything involved (followups and potential complications).

Just speculations.

Good luck
Lost Sheep
Born 1948 AMS LGX 18+3 implant Nov 6, 2017 by Dr Tavis Shaw. Spent 14 months researching in effort to optimize outcome. After 30 yrs of progressive unrecognized ED I will do this RIGHT; no second chance with one's first.
Anchorage AK, USA

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

Re: Insurance will not cover implants

Postby needhelp » Wed Feb 13, 2019 1:23 pm

Lost Sheep wrote:
needhelp wrote:Trying to find a good surgeon now.

I applaud your efforts to vet your surgeon's methodology. I passed on surgery at the V.A. in Seattle because I did not like the procedure they described. Though my medical opinion is virtually worthless, it is my penis and I wanted a different approach than they described.
needhelp wrote:They said they may change the exclution next year. I cant go this way for a year.

Speculating; this might be a way of putting you off, even though they may not have any such plans.
needhelp wrote: There is a special "grant " that ee can apply for, for unexpected emergeny expences. This is my last hope.

Again, speculating; this may be a way of appeasing you without setting a precedent of covering an expensive procedure. They could let you have the implant but not obligate themselves to do it for anyone else. Make sure the grant covers everything involved (followups and potential complications).

Just speculations.

Good luck

Thanks Lost Sheep. I always welcome your input. This whole thing may cost me 20k..... so much for my retirement fund
61 years old, single, Charlotte NC, Had a penile fracture. Implant scheduled for April 17. Dr Terlecki Winston-Salem, NC

PeteTx
Posts: 7
Joined: Mon Mar 16, 2015 9:03 pm

Re: Insurance will not cover implants

Postby PeteTx » Tue Feb 26, 2019 10:10 am

I haven't been on the site since my implant in 3/2015. My employer at the time bought coverage for ED so my implant was covered.

Forrward to last fall and a different employer (large corporation). Developed a leak somewhere and I need a replacement. Finally saw my urologist in December. He submitted a predetermination request. Insurance denied because my employer plan had a specific exclusion for any sexual dysfunction. Out of pocket was $18K.

My issue/solution was with my employer not the insurance company.

Now my new employer has a very active inclusion program and a very vocal LGBTQ social group within the corporation. Gender dysphoria is completely covered. A penile implant for gender reassignment is covered but not for Peyronie's, venous leakage, or even prostatectomies! Bottom line is a lady transitioning to a man can get an implant but not for a guy staying a guy even after cancer.

So, in January, I brought the sex discrimination to the attention of the corporate ethics, legal, and benefits departments. I cited several govt regulations but specifically:
https://www.eeoc.gov/policy/docs/benefits.html#B.%20Health%20Insurance%20Benefits%20(T7)
EEOC Compliance Manual
Chapter 3: Employee Benefits
Title VII /EPA Issues
II. Discrimination Based on Sex, Race, Color, National Origin, or Religion
B. Health Insurance Benefits
Like retirement benefits, health insurance benefits must be provided without regard to the race, color, sex, national origin, or religion of the insured. An employer must non-discriminatorily provide to all similarly situated employees the same opportunity to enroll in any health plans it offers. An employer must also ensure that the terms of its health benefits are non-discriminatory. In evaluating charges that an employer has discriminated in the terms of health benefits it offers, the following principles apply:

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.


The benefits department jumped right on it. It took several weeks to implement backdated coverage for organic/physiological sexual dysfunction to 1/1/19 to avoid fines and penalties. I believe it was not intentional. They thought they were denying "cosmetic enhancement" not a legitimate medical need.

I didn't have to file an official complaint, but if I did, they are prohibited from any form of retaliation. Retaliation would result in fines, penalties, and/or monetary compensation to you.

Also, you have between 180 to 300 days to file an offucial complaint. If you're past the window have your doctor obtain another denial to restart the period to file.

I hope this helps.

BTW: My surgery is scheduled for 3/12/19.
59 yo, diabetes, Peyronie's, and phimosis. Implanted with AMS CX700 and circumcised on the 3/23/15 by Dr. Robert Cornell in Houston, TX. Revision scheduled for 3/12/19 by Dr. Bryan Kansas in Austin, TX.

MUNKY_BUTTR
Posts: 40
Joined: Mon Sep 22, 2014 10:09 am

Re: Insurance will not cover implants

Postby MUNKY_BUTTR » Wed Feb 27, 2019 12:37 pm

So, does insurance not cover just the implant? Or both the implant and surgery? My memory fails me, but I feel like when I had my surgery in 2014, my insurance at the time wouldn't cover the implant, but they covered the surgery. Anything out of pocket I was able to finance, interest-free, with the hospital, so I've been paying $100 a month since my surgery. Only have 5 more payments left.

I'm contemplating a revision, and I'm looking at the SPD for my current insurance, and while they'll cover penile prosthesis for gender dysphoria, they also say they won't cover prosthetic devices that are fully implanted in the body, other than breast prosthesis :roll:
38 years old, single in Washington, D.C. Implanted 11/20/2014 by Dr. Kramer with an AMS CX 21cm with 1cm tips.

Lost Sheep
Posts: 2139
Joined: Mon Jul 04, 2016 11:16 pm

Re: Insurance will not cover implants

Postby Lost Sheep » Wed Feb 27, 2019 1:00 pm

MUNKY_BUTTR wrote:So, does insurance not cover just the implant? Or both the implant and surgery? My memory fails me, but I feel like when I had my surgery in 2014, my insurance at the time wouldn't cover the implant, but they covered the surgery. Anything out of pocket I was able to finance, interest-free, with the hospital, so I've been paying $100 a month since my surgery. Only have 5 more payments left.

I'm contemplating a revision, and I'm looking at the SPD for my current insurance, and while they'll cover penile prosthesis for gender dysphoria, they also say they won't cover prosthetic devices that are fully implanted in the body, other than breast prosthesis :roll:

Out of curiosity, for this question probably has no bearing on your particular case but what about an insulin pump or the devices commonly used to regulate heartbeat? Joint replacements?

From that list, it sounds to me like you are being fed a line.

Restoration of a lost bodily function to disease or injury (or failure of something previously covered) ought to be covered, I would think.
Last edited by Lost Sheep on Wed Feb 27, 2019 3:58 pm, edited 2 times in total.
Lost Sheep
Born 1948 AMS LGX 18+3 implant Nov 6, 2017 by Dr Tavis Shaw. Spent 14 months researching in effort to optimize outcome. After 30 yrs of progressive unrecognized ED I will do this RIGHT; no second chance with one's first.
Anchorage AK, USA

David_R
Posts: 1698
Joined: Mon Nov 02, 2015 1:03 pm
Location: Northeast Maryland

Re: Insurance will not cover implants

Postby David_R » Wed Feb 27, 2019 3:54 pm

MUNKY_BUTTR wrote:they also say they won't cover prosthetic devices that are fully implanted in the body, other than breast prosthesis.

This where someone (maybe from the doctor's office or somewhere else) needs to call them about gender discrimination (women don't need breast implants to stay alive, but if they are covered, then so should penile implants be covered).
Age 69. Prostatectomy in 2000. My urologist (for over 20 years) has been Dr. Marc Siegelbaum of Chesapeake Urology, in the Baltimore suburb of Towson. I have LGX, and after regular inflating I regained my original length. (My wife and I love it!)

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

Re: Insurance will not cover implants

Postby needhelp » Wed Feb 27, 2019 5:21 pm

AMS has a team devoted to trying to put some heat on the insurance companies. We are starting the process now. AMS said this team is especially designed for this. It is way over my head to go in as a nobody trying to get this approved. Im not getting my hopes up but I have to try. All I know is this, Wells Fargo has 1000's of employees. I find it hard to believe that there has not been 1 guy who is an EE of Wells Fargo that has not had their prostrate removed and as a result damage some nerves which has taken away his ability to ever have sex again (and maybe have a family) with out an implant. I'm curious if WF has denied this poor guy an implant? I'm wondering if that has ever happened or what their answer would be??? So much bullshit ...... when it coms to guys sexual health our government and insurance companies could give a shit about us guys! Sorry for the rant, just pisses me off .....
61 years old, single, Charlotte NC, Had a penile fracture. Implant scheduled for April 17. Dr Terlecki Winston-Salem, NC

PeteTx
Posts: 7
Joined: Mon Mar 16, 2015 9:03 pm

Re: Insurance will not cover implants

Postby PeteTx » Wed Feb 27, 2019 10:42 pm

Virtually all large corporations pay their own claims and use insurance companies to process the claims and send them the bill. For me, my company uses Aetna and specifically added gender dysphoria coverage but not sexual dysfunction coverage. Gender dysphoria and sexual dysfunction are additional coverages a business must add to Aetna"s plan. Essentially my company paid for a benefit/treatment/procedure for females but not for males. Breast implants post mastectomy are required coverage by federal law. ED meds were covered under a separate pharmacy policy.

Coverage to provide an implant to reassign sex from female to male was heralded corporate wide. But corporate decided not to add the extra coverage for sexual dysfunction. So Aetna categorically denied implants, pumps, injections, corrective surgery, etc. for ED, Peyronie’s, or for prostatectomy.
Blatant sex discrimination.
59 yo, diabetes, Peyronie's, and phimosis. Implanted with AMS CX700 and circumcised on the 3/23/15 by Dr. Robert Cornell in Houston, TX. Revision scheduled for 3/12/19 by Dr. Bryan Kansas in Austin, TX.


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