Insurance coverage

[MK1965]

I am 53 now. Had RP in November 2016. My recovery of erectile function did not go well. Already exhausted all non invasive options; PDE5 inhibitors Cialis and Viagra, VED pumps and for past 14 months injections TRIMIX and BIMIX. I feel it is time for implant. Heard, lots of insurance company denied insurance coverage for IPP. I have insurance thru my employer.(Aetna).
I would like to hear from recent implantees how did it go with their insurance. Was it approved at the first or after it was denied?
Any response and good advice is highly appreciated.

MK

[rancher]

Hey Mk
I also had Aetna through employer previously. Went to doctor for initial evaluation and was told to wait till I got on Medicare (which was only a couple of months) to have the surgery, because Aetna would not pay for it and Medicare would. I've since had the surgery (now on Medicare with supplement through Aetna) and am waiting for the bill. Hopefully no bad surprises.
You can always call you Insurance Rep and ask what is covered and what is not.

Good luck.

[radioradio]

MK,

I had United Health Care and had already reached my annual out-of-pocket maximum courtesy of the prostatectomy and all of its attendant testing, etc. So my bill for the implant was a big fat zero $0.00. I then had my revision before year end, and again I owed nothing.

Other than my more compressed time frame, your story matches mine perfectly. I would say you've suffered enough. Time to get it "fixed".

And let me guess; the prostate surgeon missed telling you about the loss of length, or bullshitted you like mine did and told you they'd pull the base of the bladder down to replace the length of urethra they'd be removing. If I hadn't asked about the potential for loss, it would have never been mentioned.

Wish you the best. Don't wait any longer. If I had it to do over again, I'd have had an implant about 4 years ago -- way before the PCa diagnosis and removal.

Bob

[CTR5000]

Medicare Primary and Aetna Secondary here. I hit my out-of-pocket deductible within the first month of each year just based on prescriptions. My implant was paid-in-full: Surgeon Fee; Surgical Suite; Hospital Overnight Stay; Cost of Implant itself.

Was approved right away... no appeal required. No prostate surgeries prior... all based on ED alone.

[MK1965]

radioradio,
You are absolutely right. Same B/S with me. When I asked about loss of length, my surgeon was kind of offended. His response was of dropping bladder down to compensate or length of prostate. Later he said at the max in very complicated cases loss might go to a max of 1/4 inches.
I lost 2+ inches. That is 8-10 times his mentioned maximum.
I am looking for implant urologist in Houston and plan to make appointment maybe next month or as soon as I can get one.
Thanks for your info and encouragement.
I appreciate it.
MK

[MK1965]

CTR500,
I appreciate your response. I knew about Medicare coverage but I am to far from that. If my insurance does not cover implant than I have to wait another at least 12 years. Who knows if I will need implant at that age. I need it now when my wife and I are able to enjoy it.
I plan soon to see implant surgeon.
MK

[DroptheMike]

I have employer coverage from Aetna. It is Choice POS II. The operation was covered in full for me. I don't even know how much they paid. Don't necessarily care either. Interestingly they gave me a hard time about paying for the penile Doppler test but eventually they paid for that too.

From the Aetna web site...

Aetna considers implantation of semi-rigid penile prostheses or inflatable penile prostheses (implantable penile pumps) medically necessary for members with documented physiologic erectile dysfunction when all of the following criteria are met
Absence of active alcohol or substance abuse; and
Absence of drug-induced impotence related to: anabolic steroids, anticholinergics, antidepressants, antipsychotics or central nervous system depressants; and
Absence of untreated depression or psychiatric illness; and
Nonsurgical methods have proven ineffective or are contraindicated; and
Normal prolactin and thyroid hormone levels; and
Normal serum testosterone levels (low testosterone suggests treatable endocrine cause of impotence); and
History of organic disease including any one or more of the following:
Documented injury to perineum/genitalia; or
Major pelvic trauma affecting bladder and/or anal and/or erection control; or
Major vascular surgery involving aorta or femoral blood vessels; or
Neurological disease (eg, diabetic neuropathy); or
Peyronie’s disease; or
Renal failure; or
Secondary to spinal cord injury; or
Status-post prostate, bladder, bowel or spinal surgery; or
Vascular insufficiency or venous incompetence documented by dynamic infusion cavernosometry and cavernosography (DICC); or
Venous leak of the penis.
emoval of a penile implant is considered medically necessary for infected prosthesis, intractable pain, mechanical failure, or urinary obstruction.
eimplantation of a penile implant is considered medically necessary for persons who meet medical necessity criteria above for a penile implant and whose prior prosthesis was removed for medically necessary indications.
mplantable penile prostheses are considered experimental and investigational for other indications because their effectiveness for indications other than the one listed above has not been established.
ote: Some traditional medical plans exclude coverage of charges for the treatment of sexual dysfunction. Under these plans, procedures for treatment of impotence would be excluded from coverage. Please check benefit plan descriptions.

Good luck! Hope this helps! I am very happy with my results!

[Swimdad]

I have Aetna HMO and it covers if your DOC has the correct CPT codes. My DOC had the implant manufacturer’s offic eto reach the insurance and get something back as “ preapproved”. I took the form and confirmed with Aetna over the phone that the DOc submitted CPT codes are covered by my HMO with no need for “pre-authorization” and I only need to pay for the plan allowed maximum out of pocket of whole policy (entire family, $6800 for 2018)

The day before the surgery the hospital called me to remind me I need to pay them $175 facility fee.

I check my account and found a $43K charge from the surgery center is being reviewed. A surgeon charge of $1699 was paid on discount with $0 for me to pay. Doppler scan was paid.

Could be some bill coming my way forthe “remainder of out of pocket policy maximum”.

[alibaba]

The AMS help line is very useful to help you through the approval process. Some doctors offices are good, some not. The AMS rep will conference call your insurance company with you with the PROPER coding that makes things click. In my experience, I was denied many times due to a clause that said they will not pay for any procedure that promotes conception. Since a vasectomy is part of prostate removal surgery, I was able to void that denial after MUCH argument with them. Insurance general rule is to deny everything first, twice, second and again. If denied be sure to ask that a doctor was the one who reviewed you request. Take names.

[MK1965]

I just want to thank you all for very helpful information you provided.
Alibaba, you mentioned some horror stories with your first implant before revision by Kramer.
Who was the doc who installed it that you relate as horror.
You can PM me if you don’t want to post it on the forum.

MK