Insurance says Implant is Not Medically Necessary

[Anonymous3]

I am going thru something similar with my secondary GEHA. Read my post Big surprise in the mail.

I know you are Hturner. I was avoiding that thread because I didn't want to think of the possibility of my insurance not covering the cost, especially as in your care AFTER the surgery was performed.
I have so much on my plate right now I try to avoid anything negative unless it is a reality I need to deal with.

I'm so sorry you are going through that and I wish you the best possible outcome.

If the dont authorize it ,you may try care credit

[LMCatman]

I think mine was "medically necessary" because I had prostate cancer and a radical prostatectomy. Similar to a woman's breast reconstruction following a mastectomy, the penis implant makes me "whole" again......

[Genesis]

Obviously getting the implant for me goes beyond just infertility.
Technically I am fertile, meaning I could procreate (most likely).
What arguments can I make to the insurance provider to get around this technicality?

[Larry10625]

Obviously getting the implant for me goes beyond just infertility.
Technically I am fertile, meaning I could procreate (most likely).
What arguments can I make to the insurance provider to get around this technicality?

There have been other members who have spoken to their surgeon about writing to the insurance company on their behalf and have been successful.

Larry

[medhatg]

Obviously getting the implant for me goes beyond just infertility.
Technically I am fertile, meaning I could procreate (most likely).
What arguments can I make to the insurance provider to get around this technicality?

Not sure about the US, but for me in Canada, the doctor's staff had to write a justification to our socialized medicine admins to convert the procedure from "elective" to "necessary". They used the "irreversible" organic cause for ED (in your case, it would be venous leakage) + history of failed ED treatments + ED survey (filled by me). So I guess, your doctor should know that, if not, find another doctor I guess who's willing to support your application.

[Genesis]

There have been other members who have spoken to their surgeon about writing to the insurance company on their behalf and have been successful.

Larry

I know but I am looking for specific argument points of why I need this procedure done ( medically necessary ).
My urologist might ask me for suggestions or might omit some valid arguments.

All I can come up with on my own is that I am "incomplete" as a man without it and also that it's very psychologically damaging and leads to many issues in other areas ( self esteem, overall zest for life, depression, ect.)
I don't think either of those arguments will work.

WHY IS THE IMPLANT MEDICALLY NECESSARY?

Not sure about the US, but for me in Canada, the doctor's staff had to write a justification to our socialized medicine admins to convert the procedure from "elective" to "necessary". They used the organic cause for ED (in your case, it would be venous leakage) + history of failed ED treatments + ED survey (filled by me). So I guess, your doctor should know that, if not, find another doctor I guess who's willing to support your application.

We have already proven that is organic ED Venous Leakage with history of the other treatments.
They said they would pay for it. Then some son of a bitch in the authorization/review department reviewed my case and saw a way out paying - Infertility.

It's so much more than infertility but how can I argue that it is still medically necessary beyond infertility?

[atb602]

Same shit here. Dr. Was supposed to write everything up as it was a painful condition for me and dropped the ball so my insurance was saying the exact same thing.

[ThePlumber1964]

Ask your surgeon to remove infertility out of the rational! There are others way to extract semen to procreate, but at this point you do not have other options to make love. Plain and simple.

[Larry10625]

There have been other members who have spoken to their surgeon about writing to the insurance company on their behalf and have been successful.

Larry

I know but I am looking for specific argument points of why I need this procedure done ( medically necessary ).
My urologist might ask me for suggestions or might omit some valid arguments.

All I can come up with on my own is that I am "incomplete" as a man without it and also that it's very psychologically damaging and leads to many issues in other areas ( self esteem, overall zest for life, depression, ect.)
I don't think either of those arguments will work.

WHY IS THE IMPLANT MEDICALLY NECESSARY?

Not sure about the US, but for me in Canada, the doctor's staff had to write a justification to our socialized medicine admins to convert the procedure from "elective" to "necessary". They used the organic cause for ED (in your case, it would be venous leakage) + history of failed ED treatments + ED survey (filled by me). So I guess, your doctor should know that, if not, find another doctor I guess who's willing to support your application.

We have already proven that is organic ED Venous Leakage with history of the other treatments.
They said they would pay for it. Then some son of a bitch in the authorization/review department reviewed my case and saw a way out paying - Infertility.

It's so much more than infertility but how can I argue that it is still medically necessary beyond infertility?

I think those points are valid but I'm not a doctor. The reason that I told you to ask for your doctors help is because they have does this before and they know what to say. I would offer your suggestions to your doctor to add to his own. I hope you get this worked out in a way that will give you satisfaction.

Larry

[Genesis]

Same shit here. Dr. Was supposed to write everything up as it was a painful condition for me and dropped the ball so my insurance was saying the exact same thing.

Let me get this straight - you have a malfunctioning implant and your insurance provider is refusing to cover it...
based on what?? That it won't kill you?

Is this what I have to look forward to for the rest of my life?

Hope you get that straightened out (no pun ).

I think those points are valid but I'm not a doctor. The reason that I told you to ask for your doctors help is because they have does this before and they know what to say. I would offer your suggestions to your doctor to add to his own. I hope you get this worked out in a way that will give you satisfaction.

Larry

Thanks Larry. I hope my doctor can pull the clutch save.