Anthem BCBS "not medically neccessary" depite meeting all their criteria

The final frontier. Deciding when, if and how.
ViaSwiss
Posts: 602
Joined: Fri May 24, 2019 9:09 am

Anthem BCBS "not medically neccessary" depite meeting all their criteria

Postby ViaSwiss » Sun May 09, 2021 9:17 pm

My first denial this year said it was denied because IPP was not medically necessary and then listed their criteria i.e. testosterone levels, failure of pills and injections, doppler showing VL, etc.

My Dr then did a peer-to-peer where he showed them all those things, yet I still got another letter saying it was again denied because it is not medically necessary.

My plan definitely does not have an exclusion.

Anyone have any tips of how to fight this since I have met medically necessary criteria but still getting a denial saying I have not!?
Last edited by ViaSwiss on Mon May 10, 2021 10:23 am, edited 1 time in total.
Age 35. Venous Leakage & Post Finasteride Syndrome (PFS) since age 18.
Original Implant | June 25, 2021 | 20cm Titan w 1.5cm & 1cm RTEs
Revision | November 16, 2021 | 26cm | Dr. Hakky

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

Re: Anthem BCBS "not medically neccessary" depite meeting all their criteria

Postby newbie443 » Sun May 09, 2021 9:29 pm

Call the state insurance board? See if they might be of help. IDK just thinking out loud. Good luck.
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.

Hrc714
Posts: 191
Joined: Thu Aug 24, 2017 4:13 pm
Location: Baltimore area

Re: Anthem BCBS "not medically neccessary" depite meeting all their criteria

Postby Hrc714 » Mon May 10, 2021 7:31 am

I had same experience with same insurance. I gathered all the records that showed I had tried all other options(viagra, injections, vacuum pump) over a 10 year period. There was a procedure for a written appeal to which I mailed this set of records, which included about 50 pages of doctors notes. Following that, I was approved. I really think they just deny the procedure knowing that a large percentage will let it go. Once the paper trail is in place, it becomes a liability for them to reject a legitimate claim, so in the end they act to protect themselves.
Reaction to Viagra - Sudden hearing loss
Tri mix pain and loss of effectivity
Implant July 2017, AMS 700, 24 X 12 MM, 2 x .5 CM extension.
Implant failed Nov , 2021
Revision March 2022, Titan 26 cm.

cbinspok
Posts: 574
Joined: Wed Feb 03, 2021 7:45 pm

Re: Anthem BCBS "not medically neccessary" depite meeting all their criteria

Postby cbinspok » Mon May 10, 2021 8:28 am

Hrc is correct, My very smart daughter worked in side the INS industry and says Hell yes - they deny in hopes people give up, that saves them big bucks. Anthem is one of the worst- give um hell
67years,fighting ed for over twenty years. A sever break, vit E, pataba, Viagra, massage Ved cilas, and I'm tired- throwing in the towel, Op for implant Mar 18, 2021 AMS LGX 18 x12 + 1 3cm RTE, gained girth and length, very glad I took the hard step.

FMLFML85
Posts: 578
Joined: Thu May 10, 2018 12:18 am

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Postby FMLFML85 » Mon May 10, 2021 12:23 pm

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Last edited by FMLFML85 on Sun Jun 12, 2022 4:03 pm, edited 1 time in total.

Old Guy
Posts: 2473
Joined: Tue Mar 31, 2020 4:31 pm
Location: Ohio

Re: Anthem BCBS "not medically neccessary" depite meeting all their criteria

Postby Old Guy » Mon May 10, 2021 3:45 pm

Sounds like you have the necessary paper work trail. Keep plugging away at them.
I always want to ask some of them insurance folks "What you couldn't have sex anymore?"
Nov. 8, 2019
4+ years, Coloplast Titan OTR
Married 36 years to my beautiful young bride
Always here to answer questions if you PM me


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