Insurance coverage?

[Rider1400]

I’m 57 and way past ready for an implant. I want to use Dr Wierschem at Dallas mens Health. He is listed as In the top 95% of implanters and has certifications thru Dr Perito At coral Gables in Florida and does the same minimally invasive intrapubic aproach. Question is at first The lady there said that Blue cross Blue Shield doesn’t usually cover implants. Then goes on to tell me that she’s not the actual person who does the insurance pre qualifications. The one who does is out with Covid and might be back in next week. I’ve done research till I’m exhausted and frustrated… found a sight at New York Urology that clearly stated that BCBS of Illinois covered implants which is the policy I have another sight I found shows BCBS of Illinois covers them also and both mention PPO which mine is. I spent almost 2 hours on the phone with BCBS to absolutely NO answers… they always say have a Dr submit a request. Please!!!! Tell me your insurance stories!! I’m 57 and work for a Big manufacturing plant and have a really good BCBS policy… so far….

[tobenormalagain]

I'm 55 and just today, met with my surgeon to discuss implantation. I also have BCBS (Regence) and in anticipation called their office to inquire as to reimbursement. I was told emphatically that penile prostheses were an "excluded procedure". My doctor told me today that many insurance carriers, including BCBS, are very hit and miss even with a letter of necessity. It just frost me all the $ I have paid over the years in insurance premiums and have neverhad had surgery or even a minor procedure. As a last resort, I'm bracing myself to pay the $17,000 OOP if they don't provide coverage. Good luck to us both as I'm sure we'll need it.

[Gt1956]

I'm fairly certain that insurance policies can & do vary state to state. Even by employer in many cases. I think the only method is to make sure that your doctor has a billing staff that is very well versed on the billing codes that trigger coverage. Good luck guys.

[68CatFan]

Two years ago, when I had to decide between Trimix and an implant I called my provider BCBS of Illinois and they said they cover implants.

[October26]

I have United Healthcare and the policy excluded implanted devices. My surgeon sent in the request and it was denied. I prepared a carefully worded appeal and it was accepted within four days. Whew!

Don’t give up if you are denied.

[newbie443]

My BCBSKS plan does cover implants for physical damage but only with local low volume doctors that do not do revisions. And several of the big-name doctors would not take policy. I buy my own insurance from BCBSKS and it is the same as a marketplace plan. As your policy is through your employer you need to check and see if the implant coverage was excluded to save your employer and employees money. My policy also states that prior approval from BCBS is needed. I can go online with BCBS and read my policy. You might take a look at yours and see if it has an exclusion section. I posted the location by section in some other old posts I made. You might look for them if you like.

Good luck with this. I hope you do not have an exclusion in your policy and the doctor you want for this is in your coverage area.

[Rider1400]

Two years ago, when I had to decide between Trimix and an implant I called my provider BCBS of Illinois and they said they cover implants.

Thanks CatFan that at least gives me some hope. Now if the guy in Dallas will dig into mine and see if it will cover it out of state as I live in Arkansas. I guess worse case I can go with my current Dr in Little Rock, he only does a few a year. There’s another Dr in his group that does 40-50 a year and is probably in the top in Arkansas. He’s local and will take what I can get ultimately.

[Agfa13]

At roughly $35K a pop for the surgery, I had 3, yes, it would be VERY good idea to make sure you are covered. Out of pocket, for the 2 years, was about $12K ($12K out of $105K, I win!). Guys on here paid far less, but, like a said, roughly $30K a pop....
Usually, the Clinic (whoever their insurance guru is there) will work with you and Dr. to find those 'trigger' words that will allow coverage. Good luck.