Insurance Denied Coverage for Implant

The final frontier. Deciding when, if and how.
barney1962
Posts: 2
Joined: Sat Oct 28, 2023 3:50 pm

Insurance Denied Coverage for Implant

Postby barney1962 » Mon Nov 20, 2023 1:36 pm

So disappointed. Was scheduled for inflatable implant on December 20th and just got a letter from insurance saying it’s not a covered service. Thing is it’s listed in benefit booklet as covered. Just sent a appeal letter but it’s frustrating. Been suffering with Ed for over 20 years and tried the pump, pills, and injections. All insurance plans should cover this.

Floridaspeedo
Posts: 300
Joined: Fri Jun 17, 2022 11:15 am

Re: Insurance Denied Coverage for Implant

Postby Floridaspeedo » Mon Nov 20, 2023 2:16 pm

Keep working with the doctor. Sometimes it takes two or three tries to get it approved
ED survivor 5 years. Tried pills, Gainswave, PRP, Bi-Mix/Tri Mix (worked 50% but very painful for 24 hours after injection.) 55 Gay - Single Titan Coloplast implanted June 1st, 2022, scrotal in Miami by Dr Billy Cordone..,very happy. Zero regrets

Old Guy
Posts: 2590
Joined: Tue Mar 31, 2020 4:31 pm
Location: Ohio

Re: Insurance Denied Coverage for Implant

Postby Old Guy » Mon Nov 20, 2023 3:00 pm

Definitely appeal it. Rep from my insurance called and tried to talk me out of it. Took two tries for surgeon's billing office to get me approved.
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

Lost Sheep
Posts: 6156
Joined: Mon Jul 04, 2016 11:16 pm

Re: Insurance Denied Coverage for Implant

Postby Lost Sheep » Mon Nov 20, 2023 5:16 pm

barney1962 wrote:So disappointed. Was scheduled for inflatable implant on December 20th and just got a letter from insurance saying it’s not a covered service. Thing is it’s listed in benefit booklet as covered. Just sent a appeal letter but it’s frustrating. Been suffering with Ed for over 20 years and tried the pump, pills, and injections. All insurance plans should cover this.

Old guy mentioned it, but did not suggest it directly, so I will. Ask your surgeon's office for help in pursuing the appeal. You may want to enlist the aid of your firm's Human Resources department as well. They have an interest in making sure the insurance company honors their promises and if the insurance company feels they may lose the contract with your employer...well that hits them in their (pocketbook) incentive soft spot.
Lost Sheep
AMS LGX 18+3 Nov 6, 2017
Prostate Cancer 2023
READ OLD THREADS-ask better questions -better understand answers
Be part of your medical team
Document pre-op size-photos and written records
Pre-op VED therapy helps. Post-op is another matter

treetop
Posts: 314
Joined: Mon Mar 14, 2011 12:28 pm
Location: Southern California

Re: Insurance Denied Coverage for Implant

Postby treetop » Mon Nov 20, 2023 5:31 pm

Can we ask what insurance company?... Aetna, BC/BS, Medical, etc.
Treetop
Implanted on 6/14/2024 at Manhattan ENT Hospital NY.
Titan Coloplast 22cm by Dr. EID - 40% venous leak.
Thanks to Franktalk I have been planning this for over 5 years.
My Introduction - http://www.franktalk.org/phpBB3/viewtop ... =14&t=7775

JetAirliner
Posts: 23
Joined: Mon Aug 07, 2023 7:25 pm

Re: Insurance Denied Coverage for Implant

Postby JetAirliner » Mon Nov 20, 2023 5:49 pm

Lost Sheep wrote:
barney1962 wrote:So disappointed. Was scheduled for inflatable implant on December 20th and just got a letter from insurance saying it’s not a covered service. Thing is it’s listed in benefit booklet as covered. Just sent a appeal letter but it’s frustrating. Been suffering with Ed for over 20 years and tried the pump, pills, and injections. All insurance plans should cover this.

Old guy mentioned it, but did not suggest it directly, so I will. Ask your surgeon's office for help in pursuing the appeal. You may want to enlist the aid of your firm's Human Resources department as well. They have an interest in making sure the insurance company honors their promises and if the insurance company feels they may lose the contract with your employer...well that hits them in their (pocketbook) incentive soft spot.


Agreed with Lost Sheep …. In my case I was denied three times (Cigna) before getting approved and I am 10 weeks post op … In my case to make sure everyone had skin in the game- I had my attorney send a letter to my insurance company, insurance broker, while copying in my HR department with a letter from my surgeon regarding the appeal… Everything was approved 3 weeks later … Keep fighting as the insurance companies are banking on individuals giving up

barney1962
Posts: 2
Joined: Sat Oct 28, 2023 3:50 pm

Re: Insurance Denied Coverage for Implant

Postby barney1962 » Mon Nov 20, 2023 5:58 pm

This was Anthem Blue Shield. I’ll see how the appeal goes. Doctor didn’t seem to be interested on the appeal bu I’m not going to let it drop. Only thing is I work for a small company and wanted it to stay under the radar with the coworkers. Might have to push it though.

Time2Change
Posts: 416
Joined: Sun Sep 13, 2020 7:32 am

Re: Insurance Denied Coverage for Implant

Postby Time2Change » Mon Nov 20, 2023 7:28 pm

Make sure your doctor is submitting the appeal with the correct codes.

Ultimately, that's what needed to be corrected in order to get approval from my insurance company.
55; ED for 22+ years; Coloplast Titan implant on 10/26/20; Dr. Martin Gross; Happy to share my experiences in private messages

Bent Ben
Posts: 141
Joined: Sun Jul 02, 2023 4:21 am

Re: Insurance Denied Coverage for Implant

Postby Bent Ben » Tue Nov 21, 2023 8:18 am

barney1962 wrote:This was Anthem Blue Shield. I’ll see how the appeal goes. Doctor didn’t seem to be interested on the appeal bu I’m not going to let it drop. Only thing is I work for a small company and wanted it to stay under the radar with the coworkers. Might have to push it though.

Anthem is usually pretty good about this. Is your insurance employer sponsored thru the state exchange? If so keep appealing.
If it is straight employer sponsored then you may need to reach out to your employer’s HR department and have them turn on coverage for “sexual disfunction”. Ask your doctor for the insurance code they are submitting and give it to HR.
Many times the insurance company is just following thru on the dictates of the employer. At the same time the employer will decline coverage en masse without an understanding of what the insurance companies are listing under specific codes and titles. I can see where a benefits admin says no to “sexual health” thinking they'll be paying for recreational Viagra and non-reconstructive breast jobs. The insurance companies will put surgeries like ours or breast augmentation after cancer in there knowing the admins will decline coverage because of the aforementioned.

Stay diligent
51yo, ED 5 years, 45-50° curve/PD. 22cm Titan, IP with no RTE by Dr Hakky on 9/12/2023.
My comments, suggestions, ideas or routines are for entertainment and satirical purposes only. Do not use any of my ideas, suggestions, routines or advice.

Lost Sheep
Posts: 6156
Joined: Mon Jul 04, 2016 11:16 pm

Re: Insurance Denied Coverage for Implant

Postby Lost Sheep » Tue Nov 21, 2023 9:07 am

Yes to the prior posts. Health insurance is not for enhancement of a natural function, but RESTORATION of a lost function or reconstruction after an injury or disease is definitely in the intention of most insurances. Approach the appeal with that embedded in the text.
Lost Sheep
AMS LGX 18+3 Nov 6, 2017
Prostate Cancer 2023
READ OLD THREADS-ask better questions -better understand answers
Be part of your medical team
Document pre-op size-photos and written records
Pre-op VED therapy helps. Post-op is another matter


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