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Good morning everyone. I apologize in advance for the long winded post. I've been talking with both my doctor's office, and Blue Shield of California customer service. There seemed to be a disconnect between the two when requesting approval for a penile implant. Blue Shield had no record of a request for authorization being sent.

Yesterday, after 6 weeks, I finally received a message from the doctor's office stating that Blue Shield received their request for approval, but does not do a pre-service review because the procedure is already approved under my insurance (provided it is medically necessary)The final determination for insurance payment will be reviewed at the point the claim is made.

My doctor has determined that I have a venous leak, and has submitted that information to Blue Shield. I have struggled with ED since my early thirties, and pills have completely stopped working. I'm so tired of dealing with this issue that I want a permanent solution.

Although my doctor has determined that the procedure is medically necessary, Blue Shield reserves the right to make the final decision. Has anyone else had to roll the dice with this type of scenario? If it is ultimately denied, I will be on the hook for the entire bill.

I was provided with the insurance coding from the doctor, and will be calling Blue Shield later today to see if I can get some insight, and clarification.

The doctor's office is a Boston Scientific Center of Excellence, and does a large number of implants. I am slated to get the AMS 700CX. If I have to foot the bill, I'm am considering requesting the Tactra due to the reduced cost. I also like the idea of a malleable although I have teens at home, and have concerns about the concealment issue. They still like to jump on me, and wrestle with me. That would be an awkward conversation to have with them especially because they are girls.

Any advice would be greatly appreciated as I try to navigate this issue.

Thank you

Ps...I will update my profile, but for now I am 52, 7 inches, but do not have an accurate girth measurement. I've tried all the pills, therapy with a counselor, I eat right (most of the time) and exercise. I have no reservations about the surgery, deal with pain well, and understand that an inflatable implant is a temporary solution as it is a mechanical device that will eventually need to be replaced.

i have BCBS PPO California. I had not issues with getting my surgeries covered with Dr. Patel and owed nothing out of pocket.

Similarly, the insurance company in the policy has deemed medically necessary and would provide coverage. There was no prior authorization needed or obtained by the doctor.

JohnDoe wrote:Good morning everyone. I apologize in advance for the long winded post. I've been talking with both my doctor's office, and Blue Shield of California customer service. There seemed to be a disconnect between the two when requesting approval for a penile implant. Blue Shield had no record of a request for authorization being sent.

Yesterday, after 6 weeks, I finally received a message from the doctor's office stating that Blue Shield received their request for approval, but does not do a pre-service review because the procedure is already approved under my insurance (provided it is medically necessary)The final determination for insurance payment will be reviewed at the point the claim is made.

My doctor has determined that I have a venous leak, and has submitted that information to Blue Shield. I have struggled with ED since my early thirties, and pills have completely stopped working. I'm so tired of dealing with this issue that I want a permanent solution.

Although my doctor has determined that the procedure is medically necessary, Blue Shield reserves the right to make the final decision. Has anyone else had to roll the dice with this type of scenario? If it is ultimately denied, I will be on the hook for the entire bill.

I was provided with the insurance coding from the doctor, and will be calling Blue Shield later today to see if I can get some insight, and clarification.

The doctor's office is a Boston Scientific Center of Excellence, and does a large number of implants. I am slated to get the AMS 700CX. If I have to foot the bill, I'm am considering requesting the Tactra due to the reduced cost. I also like the idea of a malleable although I have teens at home, and have concerns about the concealment issue. They still like to jump on me, and wrestle with me. That would be an awkward conversation to have with them especially because they are girls.

Any advice would be greatly appreciated as I try to navigate this issue.

Thank you

Ps...I will update my profile, but for now I am 52, 7 inches, but do not have an accurate girth measurement. I've tried all the pills, therapy with a counselor, I eat right (most of the time) and exercise. I have no reservations about the surgery, deal with pain well, and understand that an inflatable implant is a temporary solution as it is a mechanical device that will eventually need to be replaced.

I have a bronze EPO Anthem Blue Cross plan in California and went through something similar back in February this year.

When I read my plan details before I met with my doctor it said that erectile dysfunction was not covered and specifically said implants are not covered. So when I met with my doctor I figured I would be paying out of pocket. But, he and his staff said they would contact my insurance and inquire. A few days later they told me the same as you were told... it is covered and no pre-approval was necessary. And, sure enough, they covered it. Obviously there's no guarantees with these f'ing companies.. I usually have horrible experiences, but this turned out great for me. Best of luck to you!

[quote="JohnDoe"]Good morning everyone. I apologize in advance for the long winded post. I've been talking with both my doctor's office, and Blue Shield of California customer service. There seemed to be a disconnect between the two when requesting approval for a penile implant. Blue Shield had no record of a request for authorization being sent.

Yesterday, after 6 weeks, I finally received a message from the doctor's office stating that Blue Shield received their request for approval, but does not do a pre-service review because the procedure is already approved under my insurance (provided it is medically necessary)The final determination for insurance payment will be reviewed at the point the claim is made.

My doctor has determined that I have a venous leak, and has submitted that information to Blue Shield. I have struggled with ED since my early thirties, and pills have completely stopped working. I'm so tired of dealing with this issue that I want a permanent solution.

Although my doctor has determined that the procedure is medically necessary, Blue Shield reserves the right to make the final decision. Has anyone else had to roll the dice with this type of scenario? If it is ultimately denied, I will be on the hook for the entire bill.

I was provided with the insurance coding from the doctor, and will be calling Blue Shield later today to see if I can get some insight, and clarification.

The doctor's office is a Boston Scientific Center of Excellence, and does a large number of implants. I am slated to get the AMS 700CX. If I have to foot the bill, I'm am considering requesting the Tactra due to the reduced cost. I also like the idea of a malleable although I have teens at home, and have concerns about the concealment issue. They still like to jump on me, and wrestle with me. That would be an awkward conversation to have with them especially because they are girls.

Any advice would be greatly appreciated as I try to navigate this issue.

Thank you

Ps...I will update my profile, but for now I am 52, 7 inches, but do not have an accurate girth measurement. I've tried all the pills, therapy with a counselor, I eat right (most of the time) and exercise. I have no reservations about the surgery, deal with pain well, and understand that an inflatable implant is a temporary solution as it is a mechanical device that will eventually need to be replaced.[/quote

Weird, I had Blue Shield and it was almost 100% covered.
Bumper to bumper.

I have BCBS and have had 2 implants with no issues. My out of pocket expense for the last one was totally around $4k, in 2024. Hopefully you can get the implant of your choosing.