Insurance has denied implant

The final frontier. Deciding when, if and how.
October26
Posts: 382
Joined: Sun Sep 20, 2020 2:17 pm

Re: Insurance has denied implant

Postby October26 » Thu May 25, 2023 10:24 pm

cth524 wrote:Ok so as you read my insurance has denied my implant. I have cigna through my work but they use evicore I guess as a final say. I have been back and forth between different people with different answers as to if it would be approved or not. They say that evicore says it's not medically necessary when it is. I had a radical Prostatectomy done for prostate cancer almost 2 years ago. That's 2 years with Ed that nothing has seemed to help but maybe injections. I hate them cause they are causing so much scar tissue it's making my dick look deformed.
Cigna says my plan doesn't cover implants but they say my dr can argue the fact its necessary. This is all so upsetting because I thought this would be my end to ed and move on with life. I'm 53 and single and would love to met someone one day and enjoy life with. I sometimes wish I had kept my prostate cancer and died from it then to live with Ed all my life now and die from loneliness.


United Healthcare denied my procedure bc it was expressly excluded. I appealed and they promptly agreed to pay for it. I suggest you do some research about their coverages and the definition of medically necessary. Good luck.
Coloplast Titan 22 cm + 1.5 cm RTE 10/26/2020

eddie054
Posts: 26
Joined: Mon Jan 16, 2023 2:37 pm

Re: Insurance has denied implant

Postby eddie054 » Thu Jun 01, 2023 6:56 pm

I have Meritain by Atena and they denied me, however there was communication through tha doctors office and the hospital saying it was covered so I went for it. Looks like an insurance company employee or two gave contradictive information. Now my EOBs have a grand total of $63,500. Maybe I can renegotite with the hospital to lower the price. Ruined my life. If I could do it again I would find a doctor that specializes all inclusive no hidden chargea, at a surgery center and just do a mallable instead od the AMS 700 LGS.
Implanted with AMS 700 LGX on April 28, 2023. Viagra no longer worked and tried injections but didn't always work and felt achy.
68 years old.

Txagq8
Posts: 742
Joined: Tue Oct 01, 2019 4:41 pm
Location: Texas Hill Country

Re: Insurance has denied implant

Postby Txagq8 » Thu Jun 01, 2023 7:49 pm

Don’t pay anyone, anything except for what could be considered a reasonable or customary copay. What percent would you have paid had it been surgery to repair a hernia or fix a varicocele? In my mind, it would be ok to pay that much to show you are acting in good faith.

It is not your fault (or really your problem) that someone at the insurance carrier gave out bad info or the folks at the hospital messed up. If they weren’t certain your insurance would cover it, they should never have put you on the table.

Don’t misunderstand me. I’m a firm believer in paying just debts. The issue becomes defining a just debt.

If you have an attorney, I would be inclined to have him or her draft letters to the insurance carrier snd the hospital and ask that they investigate to determine who was negligent in their determination that insurance would pay.

You can’t let this ruin your life. They’re not going to sneak in and repo your LGX. I suspect you won’t ever see this on a credit report, either. For a myriad of reasons way past overdue medical bills never seem to show up at credit reporting agencies.

Best case hospital writes off the bill except for reasonable & ordinary co-pay, or insurance carrier ponies up the amount insurance carriers typically pay for uncomplicated implant (around 20K). Somebody messed up and it wasn’t you, the patient.

Worst case the attorney negotiates hospital down to the amount typically paid in a cash transaction, between 17k and 20k.

Quick story: I’m an Army retiree covered by Tricare. Several years back I sliced the hell out of thumb. Trip to ER for tetanus shot and 6 stitches.

They billed Tricare 16,000. I got a bill for my share which was 3,200. I got to looking at bill closely and one of the charges was something called “Level 1 Trauma Room.” I ended up investigating and that was a charge normally seen for heart attacks, bad car wrecks, or gunshot wounds.

I called Tricare to alert them to suspected fraudulent charges but they had already paid their designated amount. So whenever the credit collectors started harassing me on phone, I would just remind them I suspected fraud in the billing process and had no intention of paying, Tricare had already overpaid them, and these continued calls were being recorded. Fairly quickly the calls and letters stopped.

Yes, you signed a piece of paper stating you would pay. You also signed a piece of paper that absolved the doctor from his screwups. Had he installed that implant in your nose, you’d still be suing for malpractice.

You proceeded to have the surgery in good faith based upon their assurances that they’d contacted your insurance carrier and had dotted the “Is” and crossed the “Ts” and would be paid. Don’t accept responsibility for the mistakes of others.

Did you pay an estimated co-pay at the business office before the surgery? If you did, you’re in really good shape. Bottom line: take this slow, get competent legal advice, don’t pay for others’ mistakes, medical typically doesn’t ruin a credit score, and hospital bills are 2 or 3 times the amount they’ll be willing to accept when this happens.
Robust, adolescent 65 year old. Venous leakage forever. Used shots, shots+pills 30+ years. Married to same wife ~35 yrs. Implanted 31Dec2019 in Austin Tx. AMS 700 LGX 18 cm with 5 cm RTE.

eddie054
Posts: 26
Joined: Mon Jan 16, 2023 2:37 pm

Re: Insurance has denied implant

Postby eddie054 » Thu Jun 01, 2023 9:31 pm

Thanks for the positive advice.
Implanted with AMS 700 LGX on April 28, 2023. Viagra no longer worked and tried injections but didn't always work and felt achy.
68 years old.

ThailandBound
Posts: 966
Joined: Fri Dec 16, 2022 5:32 pm

Re: Insurance has denied implant

Postby ThailandBound » Fri Jun 02, 2023 8:42 am

October26 wrote:
cth524 wrote:Ok so as you read my insurance has denied my implant. I have cigna through my work but they use evicore I guess as a final say. I have been back and forth between different people with different answers as to if it would be approved or not. They say that evicore says it's not medically necessary when it is. I had a radical Prostatectomy done for prostate cancer almost 2 years ago. That's 2 years with Ed that nothing has seemed to help but maybe injections. I hate them cause they are causing so much scar tissue it's making my dick look deformed.
Cigna says my plan doesn't cover implants but they say my dr can argue the fact its necessary. This is all so upsetting because I thought this would be my end to ed and move on with life. I'm 53 and single and would love to met someone one day and enjoy life with. I sometimes wish I had kept my prostate cancer and died from it then to live with Ed all my life now and die from loneliness.


United Healthcare denied my procedure bc it was expressly excluded. I appealed and they promptly agreed to pay for it. I suggest you do some research about their coverages and the definition of medically necessary. Good luck.


Man, UMR, a “United Healthcare Company” denied my initial application and appeals for both Drs. Perrito & Clavell. Ended up paying out of pocket.

Water under the bridge now, but i wish i’d have had someone in my court somewhere as you did.
Active, athletic 63 years old. Sexually, still 33 in my mind and spirit. Pills and injections all worked, until they didn’t. Diagnosed with veinous leakage in 2022. Coloplast Titan. 22 CM. No RTE. Peno-scrotal. Implanted 1/4/23. Dr. Clavell.


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