How often do PPO’s deny the implant procedure?

The final frontier. Deciding when, if and how.
QuestionGuy
Posts: 128
Joined: Tue Sep 22, 2015 6:50 pm

How often do PPO’s deny the implant procedure?

Postby QuestionGuy » Tue Jun 04, 2019 9:00 pm

I have an opportunity to get an Anthem Blue Cross PPO medical plan which covers the implant procedure, (but only after authorization). The CPT code the doctor’s office gave me for the procedure is 54403. Does anyone know how common (or rare) it is for a big insurance PPO plan to deny the procedure during the authorization process? The doctor’s office would not comment. My diagnosis is hypogonadism as well as ED. I’ve tried and exhausted many treatments over the years, and this is well documented. I’m not looking for anyone to predict the future – I’m just curious as to whether it’s quite common to be denied ….or if its extremely rare to be denied… (or if it’s a mixture of denials and approvals).
I'm 55. PostFinasterideSyndrome/Peyronies . Initially had good erections but numbness. Now erections are compromised, but good sensitivity. I see Dr. Irwin Goldstein and do : TRIMIX-Clomiphene-Arimidex –Cabergoline -Cialis -Traction-VED-Pshot-gainswave

Tmansdorfer
Posts: 175
Joined: Wed Sep 14, 2016 2:36 pm

Re: How often do PPO’s deny the implant procedure?

Postby Tmansdorfer » Tue Jun 04, 2019 9:14 pm

I have an Anthem BlueCross PPO plan and it was approved along with the revision. All I paid was my out of pocket amount. I was initially worried prior to surgery that they would deny it but the surgeon told me it is all in how they word it in request letter. Good luck.
39 01/24/19 USC Dr Doumanian LGX 15cm 3, lGX 18 +2, revision 6-20 18+3 pump failure, revision 8-20 left cylinder in scrotum, 1-21 removed infection switched to dr Doyle, Boyd 10.05.21 a 15+3 cx,revision 01,23,24 with switch to LGX 15+6 fat pad removal.

newbie443
Posts: 1827
Joined: Fri Dec 01, 2017 9:41 pm
Location: Sedgwick county, Kansas USA

Re: How often do PPO’s deny the implant procedure?

Postby newbie443 » Wed Jun 05, 2019 12:13 am

I have BCBS gold plan that I buy from BCBS and is the same plan as listed on the Obama care program for my state. Each state is different a bit. My policy is the same in that it is covered but must have prior approval. It is only covered in my home area for BCBS in Kansas so the insurance company limited my area to choose a doctor for this. In my case I would choose the implant device I wanted and the business office would figure my cost. Seems to me insurance in my state only covers so much so the cost will be different depending on which device I chose. Last year I had not meet my deductible or out of pocket. I have a 1500 deductible and 3500 out of pocket and my projected cost was over 4k. So some of the cost was not covered by my plan. But again each state is different. Your doctors business office should be able to figure your cost and get the approval for this for you. They have all the documentation from your doctor to do this.
Injections failed. Implanted 3-21-18 AMS 700 LGX 21 + 1 RTE 100 cc reservoir 6.5" L 5" G Dr. Kramer.

Proximal Perforation Sling Repair 4/13/21 Dr. Broghammer

66 years young.

Will show and tell and talk with others.

505AbqNM
Posts: 44
Joined: Wed Feb 06, 2019 7:02 pm
Location: Albuquerque, New Mexico

Re: How often do PPO’s deny the implant procedure?

Postby 505AbqNM » Wed Jun 05, 2019 9:33 am

QuestionGuy wrote:I have an opportunity to get an Anthem Blue Cross PPO medical plan which covers the implant procedure, (but only after authorization). The CPT code the doctor’s office gave me for the procedure is 54403. Does anyone know how common (or rare) it is for a big insurance PPO plan to deny the procedure during the authorization process? The doctor’s office would not comment. My diagnosis is hypogonadism as well as ED. I’ve tried and exhausted many treatments over the years, and this is well documented. I’m not looking for anyone to predict the future – I’m just curious as to whether it’s quite common to be denied ….or if its extremely rare to be denied… (or if it’s a mixture of denials and approvals).


Question Guy,
I also have Anthem BCBS but it is a PPP plan. In my case, BCBS authorized the surgery for Dr Eid but that turned out to mean absolutely nothing in terms of covering the costs. The only thing that was relevant was whether or not Dr Eid was In Network, which he was not, and the Dr's office did not research that. They were just looking for 'approval' for me. Fortunately, I found out about the In Network issue before the procedure. In my case, Dr Andrew Kramer was In Network and it has worked out beautifully. So far, BCBS has paid over $23k toward the procedure with $0 out of pocket medical expenses for me. I was just out about $1500 for travel expenses.
So, my lesson learned is to confirm the In Network status of a prospective doctor before pursing approval or treatment!
As long as the doctor writes up a reasonable justification for the procedure, I cannot imagine BCBS not approving.
Good luck.
Married, age:67, work fulltime, Type2 diabetic, worsening ED since 2012, all meds ineffective by 2019. Bionic on May 1, 2019 by Dr Andrew Kramer. Titan XL, standard pump, 24cm + 1RTE, best TriMix sizes realized, G~6", L~7.5”, pump revision Nov 2019

QuestionGuy
Posts: 128
Joined: Tue Sep 22, 2015 6:50 pm

Re: How often do PPO’s deny the implant procedure?

Postby QuestionGuy » Thu Jun 06, 2019 2:22 pm

Thank you so much guys !

Question: Why did it matter if the doctor was not in network? I had just figured I'd pay the out of network rate for my doctor (since the doctor its such an important part of the equation).
I'm 55. PostFinasterideSyndrome/Peyronies . Initially had good erections but numbness. Now erections are compromised, but good sensitivity. I see Dr. Irwin Goldstein and do : TRIMIX-Clomiphene-Arimidex –Cabergoline -Cialis -Traction-VED-Pshot-gainswave

newbie443
Posts: 1827
Joined: Fri Dec 01, 2017 9:41 pm
Location: Sedgwick county, Kansas USA

Re: How often do PPO’s deny the implant procedure?

Postby newbie443 » Thu Jun 06, 2019 8:41 pm

QuestionGuy wrote:Thank you so much guys !

Question: Why did it matter if the doctor was not in network? I had just figured I'd pay the out of network rate for my doctor (since the doctor its such an important part of the equation).



No individual purchased health care plan I found last 2 years in KS had any out of network coverage. Now if I am out of state there are doctors and facilities that accept BCBS I am covered for emergencies. But this surgery is not an emergency. So for approval from my states BCBS they will only pay for part of this if I am in my home area. Like I said insurance is state by state. So your state may be different.
Injections failed. Implanted 3-21-18 AMS 700 LGX 21 + 1 RTE 100 cc reservoir 6.5" L 5" G Dr. Kramer.

Proximal Perforation Sling Repair 4/13/21 Dr. Broghammer

66 years young.

Will show and tell and talk with others.


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