Insurance Preapproval and Cost Estimate

[SW0110]

The way they explained it to me was the procedure was covered. Then it was covered for me and my conditions and they would pay for it.

Not sure about difference myself. But that is what I was told.

[mike123]

I just got a call from the insurance coordinator at the surgeon's office. She said she just got the preapproval from the insurance company. I asked her to fax it to me. Basically, when I read it, I find I still have nothing. Note that the preapproval request was accompanied by all supporting documentation that the insurance company said was required for approval. Without preapproval, I can't proceed with the surgery and it doesn't look like the insurance company wants to commit.

I could use some advice on how to proceed when my insurance company sends this to the surgeon's office.

Dear Health Care Professional:

Thank you for your benefit inquiry.

We reviewed you request for a benefit inquiry for the member listed above.
We verified procedure 54405 with diagnosis N52.01 is eligible for coverage if all other applicable plan provisions and requirements are met.

Please note: This is not an authorization, nor a guarantee of payment for the requested service(s)

As submitted, the proposed service or services do not require precertification under the member's benefits plan. However, if services other than those indicated above are provided, precertification may be required.

Final determinations of coverage are made at the time of claims submission and processing. We base payment on:

* The actual reported services
* Our payment and clinical policies
* Member eligibility at the time services are rendered
* All other plan provisions and limits

Predetermination reconsideration requests
If you disagree with this decision and/or have additional documentation not previously considered, you may submit a reconsideration review request.
Pre-service approval is not a requirement for coverage under the member's plan. So, your request for a courtesy evaluation of the proposed service(s) is not considered a claim under the Employee Retirement Income Security Act (ERISA). Therefore, there is not formal right to appeal this evaluation decision under ERISA or under the member's plan.

[Waynetho]

We reviewed you request for a benefit inquiry for the member listed above.
We verified procedure 54405 with diagnosis N52.01 is eligible for coverage if all other applicable plan provisions and requirements are met.

As submitted, the proposed service or services do not require precertification under the member's benefits plan. However, if services other than those indicated above are provided, precertification may be required.

Note what I underlined and highlighted. This isn't telling you the procedure is denied, it's telling you it's covered by your plan but no precertification is needed.

[mike123]

Exactly. It's not a denial, but it's not an approval either. It basically says they can still deny payment after surgery if the doctor failed to dot the correct i or cross the right t.

The insurance company has a list of requirements and procedures that must all be met in order for them to pay. I'm trying to get confirmation prior to surgery that all of those requirements have been met, that we aren't missing any tests and that the test results fall within the required ranges.

They don't require preapproval, but they have so many loopholes to avoid paying that you could drive a truck through it. I need to close those loopholes and this letter doesn't do it.

[jeb6294]

On the subject of insurance,has anyone found that any one insurance is better or worse for ED issues, i.e. paying for injections, paying for an implant?

I work for the gov’t and have GEHA which basically means my coverage is throughUnited Healthcare. We recently got a postcard in the mail saying that coverage was going to be switched over to Aetna for 2021. Open season starts in November so that’d be my chance to switch health insurance and then I’m stuck with whatever I’ve got until next November.

[mike123]

Hi Jeb, I think that's a great question. It would be very useful to discuss which insurance companies are better than others when it comes to covering implants. You would probably get better traction, though, if you asked it in a new thread.

[mike123]

I just spent the last couple of hours on the phone with my insurance company. It's an employer sponsored plan, and it turns out that my employer self insures. It uses the insurance company to handle claims. At the end of the day, claims are paid by my employer and it's up to them to determine what is and isn't covered. I eventually got transferred to case manager within my own company. She is going to follow up and try to get an answer for me. So, fingers crossed.

[Gt1956]

On the subject of insurance,has anyone found that any one insurance is better or worse for ED issues, i.e. paying for injections, paying for an implant?

I work for the gov’t and have GEHA which basically means my coverage is throughUnited Healthcare. We recently got a postcard in the mail saying that coverage was going to be switched over to Aetna for 2021. Open season starts in November so that’d be my chance to switch health insurance and then I’m stuck with whatever I’ve got until next November.

Retired Federal Employee here. I have Aetna under the FEHB program. I discussed coverage with Dr. Karpman's people. Also with Dr. Brant. Both indicated that Aetna does cover it. Now after saying that. Insurance companies are in their own universe. I just had a MRA in conjuction with a cardio work up. Just got a letter from the hospital that Aetna hasn't paid yet & my outstanding bill is $2,900. I'm going to wait a bit before I give Aetna a phone call about it.
Also, I get my regular prescription mail order through them which is handled by CVS. They frequently fail to auto renew or send out refills that I take on a regular basis. They are not the most effective people. But phone support is good. Always get things resolved. Just they're not resolved forever.

[SW0110]

My insurance actually said. Implants were covered for physically related ed issues or peyronies.

I had both documented by the doctor. My file documented the peyronies and 100 mg viagra would not give a solid erection, and significant venous leakage per ultrasound. I made sure it was all in there. I also would need repeated injections to get an erection. For me the implant was it.

Revision from titan to lgx was also fully covered. No issue going from one to other even though I had titan less than a year before it stopped working.