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Just an update on my insurance woes. I just received a letter yesterday 7-24-24 that states "We are pleased to inform you based on the information submitted that we are reversing your denial of service. Your claims will be reprocessed." So yes it is possible to get insurance to review and reverse decisions ( usually hard to do though ). Now in my case I had contacted Boston Scientific who in turn gave me some very good information to pass along to insurance, that with a letter of necessity from my Dr, and a letter from me detailing everything I've done from the start of my ED symptoms up to and including the surgeries probably helped. As a side note Boston Scientifics legal team reached out to get information from me on my case to see if there was anything that they could do to help my case, I don't know if they reached out to my insurance or not but things progressed pretty quickly not long after I had talked to their legal team a few times.

Since my letter did not reference or say anything about my revision I need ( 2nd device failed again so surgery number 3 for me is needed ) I called them to ask and was told for any case always ask the Dr and hospital that's doing the surgery to get a pre authorization and pre cert done before any surgery - if they have those then it has to be paid. In my case I have to have the Dr and Hospital ask for a pre authorization and pre cert and to have them reference the previous surgeries as this is a continuation of those and it is supposed to be authorized quicker than the usual process seeing as mine is a reversal of denial appeal.

So here's hoping I get my third and final surgery done with no more failures pretty soon - I plan on going from the CX over to a LGX especially since I haven't been able to cycle or do anything with this implant in over 6 months now since it failed and I'm hoping the capsule and scar tissue hasn't built up to bad in that time frame. So I got calls to make today to the hospital and Drs office to let them know the good news and to get the ball rolling on getting this next surgery scheduled and taken care of.

Congrats! That must be a relief. Best of luck with your new one.

Good news. What a pain to have to fight the insurance companies. In the meantime you suffer. Best of luck.

JohnHC I am very happy for you, let's hope it is the last implant and God bless you, I will also do a review in September if my doctor keeps his word, I will only pay for the device, who was your doctor at the first and second implant

frank66665 wrote:JohnHC I am very happy for you, let's hope it is the last implant and God bless you, I will also do a review in September if my doctor keeps his word, I will only pay for the device, who was your doctor at the first and second implant

My Dr is Dr Rajnahally ( spelling might be off ) with Urology of Greater Atlanta ( UGA ). He's a great Dr easy no nonsense guy great attention to detail and to say he was at as much a shock as I was on these two failures. Nobody at his practice has had anything like it happen so I told him that's just my luck, if there's a bad one I'll get it.

But honestly I believe the first failure was caused by someone post op while in recovery. I've heard and seen in the videos that Drs will give you long acting pain medicine before the surgery, I think the nurses forgot to do it before the surgery and just gave me the shot while in recovery to cover their tails but that they stuck the needle in my left cylinder puncturing it which forced the revision.

As for the second failure that's more difficult to know until I have the surgery but from what I can feel down there the connection between the reservoir and pump had the connection come apart by damaged connector or not being properly or fully seated during connection or the tubing broke right at the connector. When I have this revision I will let everyone know for sure what the issue was.

I'm just ready to get this next revision done and have a working implant again.

I too had my insurance deny me at first. I have Baylor Scott and White HMO from Marketplace plan. After denial I reached out to AMS hotline and they helped me with appeal. It was pretty straight forward really. BSW was claiming denial due to a paragraph in the evidence of coverage on plastic surgery. The evidence of coverage did show coverage for medically necessary prosthetic devices in the another area of the document. Als, the evidence of coverage did not have a written exclusion for the diagnosis code for ED or treatment code for penile implant. So in my appeal letter I simple explained the above in the letter and asked them to review the evidence of coverage for my plan again along with the reason of denial using the guidance of AMS. 3 weeks later BSW reversed the decision and gave me a letter of approval! Now I am sitting here with my 4 day old implant!

So hang in there guys when battling insurance. I really believe that most plans will deny first no matter what just to see what you will do or if you will appeal - making the insurance company actually look over the plan with human eyes. JMO