Anthem BCBS Prior Authorization denied

[ViaSwiss]

2019, my insurance didn't cover sexual dysfunction.
2020, no insurance + wife didn't want me to get implant.
2021, divorced her, but Anthem BCBS is denying because "its not medically necessary".

I've now had 2 dopplers show VL. I've had ED for 16+ years.

Guess its time to battle to man.

[Cajun Jeff]

Good luck. I never got anywhere with BCBS of Louisiana. I had to waif for Medicare.

[SteveSW]

2019, my insurance didn't cover sexual dysfunction.
2020, no insurance + wife didn't want me to get implant.
2021, divorced her, but Anthem BCBS is denying because "its not medically necessary".
I've now had 2 dopplers show VL. I've had ED for 16+ years.
Guess its time to battle to man.

Have you by chance had a diagnosis of any Peyronie's Disease? I know you didn't mention it, so probably not. But coded correctly by the doctors office, PD will often get the implant approved, because it is deemed medically necessary. Why treating PD is medically necessary but treating ED isn't is baffling, since both situations are about making your dick work.

[Waynetho]

2019, my insurance didn't cover sexual dysfunction.
2020, no insurance + wife didn't want me to get implant.
2021, divorced her, but Anthem BCBS is denying because "its not medically necessary".
I've now had 2 dopplers show VL. I've had ED for 16+ years.
Guess its time to battle to man.

Have you by chance had a diagnosis of any Peyronie's Disease? I know you didn't mention it, so probably not. But coded correctly by the doctors office, PD will often get the implant approved, because it is deemed medically necessary. Why treating PD is medically necessary but treating ED isn't is baffling, since both situations are about making your dick work.

Because PD is damage but ED can be natural causes.

[newbie443]

Get a copy of your insurance policy. If you are set up online you can do this online. I buy my insurance from BCBSKS. This is from the COMPREHENSIVE PROGRAM section of my policy E. SPECIAL SITUATIONS :

3. Penile Prosthesis for Physiological Impotence
Benefits are provided for a penile prosthesis required for physiological (not psychological) impotence,
subject to advance approval by the Company only in the following situations: trauma, radical pelvic
surgery, diabetes, Peyronie's Disease, vascular or neurological diseases when individual situation
warrants coverage in the Company's opinion.
To request advance approval, a written report prepared by Your Practitioner must be submitted to the
Company. The Company has the right to request and obtain medical information it considers needed to
determine whether benefits should be approved or not.
Benefits are not provided for services of sleep laboratories for nocturnal penile tumescence testing.

As you have testing that shows VL I guess you need something to show it was caused by high cholesterol or blood pressure or injury or something else. It seems VL on it's own is not enough. You may need to think back prior to ED for an injury you may have had if you have no disease or pelvic surgery to attach to this. Then have your doctors office resubmit it with the qualifier. If they did this already I would appeal. But you need the information that was submitted and find out why it was not approved.

As was said in another tread on this is it very normal that you are upset and the folks you will deal with have no trouble not helping angry people on the phone. So have a paper and pen and write down the day and time and persons name you talk to. And be nice and ask for help. Something like Hello Mary (or Bill, or what ever the name is) I need some help please. You can fight this and still be polite and nice. Things like thank you Mary for your help or Mary is there anyone else I can talk to for help with this. Have your documentation from your doctor and policy so you can give them the information. Help them help you and you.

Good luck with this and let us know what you find out.