I received denial letter from BCBS

[MTSU1992]

I received a denial letter from BCBS of TN today for a penile implant. I saw Dr. Hakky last month and was diagnosed with venous leakage. I have been on daily Cialis since 2014 and for several years it worked fairly well, but for the past few years I have not gotten sufficient results. I have also tried VED without favorable results. I have decided to forgo injections for a few reasons. So, after talking to Dr. Hakky, I decided to proceed with an implant. After receiving the denial letter today, I guess the next step is filing an appeal. Has anyone had any luck with appealing a denial from BCBS of TN? Any suggestions would be appreciated.

[lasthope2.0]

Did BCBS mention the reason for denial, such as plan or coverage exclusion?

[GoodWood]

If you don’t already have it, you need a copy of your policy. Read the exclusions section. What does it say. Chances are treatment for sexual function is excluded but you need to know the exact wording.

What does Hakky’s office staff that handle insurance documentation say? Have they dealt with BCBS of TN before and have they been able to successfully get coverage approved?

This is disappointing, but it’s not the last word. Hang in there.

[Hrc714]

I appealed BCBS and had to provide documentation that all other non surgical treatments had failed. I sent them piles of appointment receipts, prescriptions, doctors notes and a detailed letter with timelines and results. After review, I was approved. Stop here if that helps or read on for entertainment

Day of surgery I was admitted and prepped, given the antibiotics and sedatives, then started to the operating room. Due to some emergency, the operating room was pushed back to the room and told to dress and go home. Then I was billed for admission and drugs. Insurance denied that claim as unnecessary treatment. I fought and won the admission charge but the pharmacy insisted that I used the drugs so had to pay. They would not refill for my rescheduled surgery until I cleared my bill. I paid. Of course after my reschedule surgery, payment was denied due to the Drs office not coding things properly. I paid all out of pocket u til things got sorted. Then insurance paid for everything. As everyone was now double paid, I had to fight to get a refund of my payment. You think hospitals are difficult when you owe them money? Just try when they owe you money.

[danny1553]

Hospitals will reimburse you eventually but it may take years. Literally.
I had a critical Covid case in 2021 and I spent about 3 weeks at a hospital. After that I started getting a "steady flow" of bills from who-knows-what-party. I literally lost track of even what those bills were reflecting, I just accepted my fate.
In 2023 I got a few hundreds dollars check for some overcharges.

[ElbowRoom]

I received a denial letter from BCBS of TN today for a penile implant. I saw Dr. Hakky last month and was diagnosed with venous leakage. I have been on daily Cialis since 2014 and for several years it worked fairly well, but for the past few years I have not gotten sufficient results. I have also tried VED without favorable results. I have decided to forgo injections for a few reasons. So, after talking to Dr. Hakky, I decided to proceed with an implant. After receiving the denial letter today, I guess the next step is filing an appeal. Has anyone had any luck with appealing a denial from BCBS of TN? Any suggestions would be appreciated.

The problem is that every BCBS plan is different. I have BCBS of GA and it was approved on the first try. Does you plan have an exclusion for sexual treatments? Many do.

If there is no exclusion it should get covered on appeal. I recenrly had a back procedure that had to fo to second appeal before being covered. Just let Hakky keep working it for you.

There is always self pay if you can awing the cost, Hakky quoted me $29k all-in last year for the procedure in the hospital.

[MTSU1992]

It looks like my insurance does have an exclusion for erectile dysfunction. The letter states implant services are eligible if there is traumatic injury or illness. I have emailed Dr. Hakky’s office and hopefully hear back from them next week.

I did ask Chat GPT and it recommended that in the appeal letter the urologist say the implant is needed to treat an underlying vascular illness/physical pathology requiring reconstructive restoration of function instead of it is needed to treat erectile dysfunction. Documentation needs to be provided.

Chat GPT also said if the appeal gets denied to not give up. It said State of Tennessee allows for a second appeal that goes to an external review. That sounds like my best chance of getting it approved. I imagine Dr. Hakky can be very convincing in why it should be covered when not dealing with insurance company that is trained to automatically say no.

Hopefully I will hear from his office in the next week or two.

[ElbowRoom]

It looks like my insurance does have an exclusion for erectile dysfunction. The letter states implant services are eligible if there is traumatic injury or illness. I have emailed Dr. Hakky’s office and hopefully hear back from them next week.

I did ask Chat GPT and it recommended that in the appeal letter the urologist say the implant is needed to treat an underlying vascular illness/physical pathology requiring reconstructive restoration of function instead of it is needed to treat erectile dysfunction. Documentation needs to be provided.

Chat GPT also said if the appeal gets denied to not give up. It said State of Tennessee allows for a second appeal that goes to an external review. That sounds like my best chance of getting it approved. I imagine Dr. Hakky can be very convincing in why it should be covered when not dealing with insurance company that is trained to automatically say no.

Hopefully I will hear from his office in the next week or two.

Definitely go through the process, but don't get your hopes up too high. If there's a specific exclusion for ED other than traumatic injury you have a very high bar to get over. Start thinking about how to finance the operation yourself, or see if you can find a way onto a different plan.