Insurance denied revision

[oldbeek]

Did your implant fail?? Or are you trying to get a new one because the Dr installed an implant that is 2 inch short.

[Lost Sheep]

As per Aetna bulletin on Erectile Dysfunction, penile implant and revisions are covered when you meet certain criteria. In my case, I had prostate cancer and Radical prostatectomy to remove prostate.
I did use all ( Viagra, Cialis, VED, TRIMIX, BIMIX) with no success at all.
My first implant was approved in less then 10 days.
Policy did not change but people who work for Aetna are non clinical and they don’t understand whole issues. Lady that I talked today was telling me that I have to exhaust all non invasive therapy before implant will be approved.
I tried to explain that when you get an implant and it becomes non functional, nothing Else will work But another implant.
I hope my doc will be able to talk to Aetna’s doc.
MK

Perhaps if you explained to the lady that a prosthetic penile implant is not unlike a prosthetic knee implant. If a prosthetic knee fails, you cannot walk, period. If a prosthetic penis fails, you cannot fuck (oops, perhaps the other "f" word, "function" would be better accepted).

Perhaps a better analogy would be if she had saline breast implants and one of them leaked, leaving one side of her flat-chested. Would she want a replacement? Unfortunately breast implants are purely cosmetic (albeit important for self-image) and also might ruffle her feminist feathers.

[Agfa13]

This made my day!!!

[Gt1956]

As per Aetna bulletin on Erectile Dysfunction, penile implant and revisions are covered when you meet certain criteria. In my case, I had prostate cancer and Radical prostatectomy to remove prostate.
I did use all ( Viagra, Cialis, VED, TRIMIX, BIMIX) with no success at all.
My first implant was approved in less then 10 days.
Policy did not change but people who work for Aetna are non clinical and they don’t understand whole issues. Lady that I talked today was telling me that I have to exhaust all non invasive therapy before implant will be approved.
I tried to explain that when you get an implant and it becomes non functional, nothing Else will work But another implant.
I hope my doc will be able to talk to Aetna’s doc.
MK

Perhaps if you explained to the lady that a prosthetic penile implant is not unlike a prosthetic knee implant. If a prosthetic knee fails, you cannot walk, period. If a prosthetic penis fails, you cannot fuck (oops, perhaps the other "f" word, "function" would be better accepted).
Perhaps a better analogy would be if she had saline breast implants and one of them leaked, leaving one side of her flat-chested. Would she want a replacement? Unfortunately breast implants are purely cosmetic (albeit important for self-image) and also might ruffle her feminist feathers.

That line of discussion could go a lot of differen't ways.
She could be a sex hater & reply that "what do you mean, he can still pee out of it". Or even better. "Women need implants because men demand them on us".
Hard to argue with crazy logic. I wish the best luck in your appeals.

[MK1965]

I am re-scheduled for surgery on 9.9.20 pending insurance approval.
I am kind of disappointed. I already prepared my mind for surgery and recovery. Will see how it will develop with insurance.
I already failed Appeal on their decision.
I feel it won’t be approved despite need for revision.
MK

[Gt1956]

MK1965, that just plain sucks. If the insurance is through your employer? Is there a chance that at the next open season that you could switch to a better plan? Where I worked, we had our choice from a bare bones plan up to some fairly decent ones. Of course, the premium was priced according to the plan that you choose. Good luck.

[MK1965]

Gt1956,
I have same insurance which paid my first implant and I still work for the same employer I did at my first implant in 2018.
Bunch of bureaucrats are making important decisions about other people wellbeing.
MK

[Lost Sheep]

Gt1956,
I have same insurance which paid my first implant and I still work for the same employer I did at my first implant in 2018.
Bunch of bureaucrats are making important decisions about other people wellbeing.
MK

Sometimes coverage is changed from prior years. Be sure to check the policy. Also, fixing a failed implant may be covered where new prosthetics might not be. Develop your arguments like you were a lawyer. Get help from your surgeon's office if you can. Also get help from the implant manufacturer. Both have incentives to help you argue your case and have lots of experience doing so.

When dealing with the insurance company, be polite because you want these people to see you as a person, not a claim and to LIKE you and want to help you. Enlist them to your aid. Take names and say their name when you thank them at the end of all communications, even if they were no help; they did give you their time and people LIKE to hear their own name used. It makes them feel recognized and to recognize you, in turn. Take notes.

[MK1965]

LS,
As per Aetna Bulletin on erectile dysfunction, implant is still covered and revisions also. No change in that.
Pre- determination department is not willing to work with my Dr’s office.
They are saying that implant won’t be covered until I try all non invasive treatments. I can not explain to them that it is not possible to use injections after you have implant in place. Only solution for non working implant is to replace it with new one.
I submitted Appeal with operative note from my implant surgeon.
I don’t have any idea how long it takes to hear about Appeal review.
MK

[Waynetho]

LS,
As per Aetna Bulletin on erectile dysfunction, implant is still covered and revisions also. No change in that.
Pre- determination department is not willing to work with my Dr’s office.
They are saying that implant won’t be covered until I try all non invasive treatments. I can not explain to them that it is not possible to use injections after you have implant in place. Only solution for non working implant is to replace it with new one.
I submitted Appeal with operative note from my implant surgeon.
I don’t have any idea how long it takes to hear about Appeal review.
MK

Insurance companies employee MDs on their staff to make determination of coverage but it's unfortunate that any MD can be hired for the job, even a dermatologist or a psychiatrist, both of whom are obviously not qualified to made determinations on men's reproductive issues. The best they can do is cite policy without fully understanding the underlying issue. That's where being eloquent in your argument for the appeal can come in handy. Each time my UroLift procedure was turned down on appeal, I called and talked with the insurance and each time they told me what they expected *NEXT*. By the third appeal, I had completed the IPSS survey for LUTS symptoms and was approved then. They only stated one requirement that wasn't met each time they denied it, until I had completed all of them. It was nerve wracking to say the least and seriously aggravating (say "PISSED").