out of pocket costs

[tobenormalagain]

In anticipation of being implanted, I just got off the phone with my health insurance provider (Regence Blue Cross/Blue Shield) and of course, you guessed it, penile implants are an "excluded" procedure-bastards! Does anyone have any specific suggestions or advice? Are appeals ever successful? Would it be worthwhile to take out a secondary policy or would this be considered a 'pre existing condition'? At this point, I'm desperate and would be willing to pay out of pocket on a payment plan. Please help!!!

[AST2123]

Sorry to hear that.
Read the policy carefully and see if it is really mentioned as excluded. If it is an employer's plan, your employer may have chosen to exclude it.
If so, while the market place enrollment is open till Dec. 15th, I suggest you enroll through the market place, and chose a plan that doesn't exclude such a surgery. It has a certain code (I don't remember it).
I did that when my insurance rejected my implant. I enrolled to Kaiser Permanente in Northern Virginia (based on a word of mouth about the surgeon), the surgery was immediately scheduled a couple of days after my appointment with the doctor.
Other plans in your area could also cover this procedure. Check them out.
All the best!

[Txagq8]

Some guys on here have had success appealing a denial.

This has been especially true when the implant could plausibly be said to have been installed to correct Peyronie’s disease. It’s anecdotal, I don’t have numbers, but I do seem to recall that a number of guys whose insurance plans exclude the procedure were able to get it done when their doc used the Peyronie’s disease correction on them.

It’s important to read the fine print and talk to the insurance carrier. Mine excludes a penile implant for psychogenic ED, but allowed it for organic (physical cause) ED.

You can look at other insurance plans. Be sure to ask the question. The CPT code for implant surgery is 54405. Ask the question up front….does it require preauthorization, under what conditions can insurer refuse to pay, how long do you have to wait for the new insurance to cover a preecisting condition (the ED).

For what that will cost you in additional premiums, you could look at paying cash. There are good and reputable surgeons in various places throughout the US who will implant you for a price between $17k and $22k. That’s not cheap, and I didn’t have to pay much in the way of co-pay. But in be retrospect if I was a 50 year old guy I would definitely give consideration to driving a less pricey vehicle and treating myself to the surgery. It would have been worth it….emotionally, psychologically, in every respect. Your option of waiting til you’re 65 to let Medicare do it isn’t really a great alternative.

[Lost Sheep]

In anticipation of being implanted, I just got off the phone with my health insurance provider (Regence Blue Cross/Blue Shield) and of course, you guessed it, penile implants are an "excluded" procedure-bastards! Does anyone have any specific suggestions or advice? Are appeals ever successful? Would it be worthwhile to take out a secondary policy or would this be considered a 'pre existing condition'? At this point, I'm desperate and would be willing to pay out of pocket on a payment plan. Please help!!!

Appeals are successful. Certainly lack of making an appeal has a 100% failure rate. Go for it. Press HARD on the fact that this surgery is "to restore a (diminished) natural bodily function". If diminished blood flow took your foot or arthritis limited your function, would insurance cover treatment?

It is my understanding that pre-existing conditions MAY be covered after sufficient time has passed for coverage to apply. Slim odds, but a policy might be found that does.

Caveat: I have little experience with appeals, nor pre-existing conditions but have read up a bit.

[ViaSwiss]

AMS will help you try to work with your employer to do a one time exception on this "Exclusion".. contact Coordinator.Elleen@bsci.com

Other options are out of pocket... Dr Hakky is $17,000 I think out of pocket through surgeo.com
Dr Blick is $17,500

[Gt1956]

You might want to check around locally for a healthcare advocacy group. There is a chance that they might be able to steer you through the appeals process. At the very least, they could help you avoid making obvious (to them) mistakes during the first few levels of appeals.