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Need your help Frank Talk.
After claiming they would cover the cost as long as there was a prior authorization, they are now saying they do not cover the implant procedure.
That it is a cosmetic surgery and NOT medically necessary.
I'm sure some of you have already been through this bullshit. What can I say to them to prove my case?

If that is the only rationale they are using to deny coverage, that is way easier to fight. The penile implant is not a cosmetic surgery since it is not done to beatify your genitalia. It is to re-establish function to your penis.

Contacted insurance, they claim it has NOT been denied yet! It could take 14 days from when the prior authorization was sent in ( Auth was sent in over 2 weeks ago but of course they dont have that information either). I asked for clear guidelines of what would deem this procedure as medically necessary - she doesn't have that information, only the Authorization Department does but we have no way of contacting them!
This is not something I want to have hanging in the balance. I need to know whether they are going to cover this or not!
So frustrated! Wish I had the money to do this on my own terms!

Time to practice patience. You will need it a lot during the surgery recovery process!!!

I was initially declined as well. The reason was, I haven't tried Vacuum Pump or Muse. My doctor appealed the decision and won.

I'm more than ready to be patient during the healing process, what do not have the patience for is being dicked around by the insurance company.
They said they would cover it when we confirmed at the urologist, now after calling to see why they will not cover it they tell me this falls under infertility, and they do not cover infertility at all.
WOW.

PokMan845 wrote:I was initially declined as well. The reason was, I haven't tried Vacuum Pump or Muse. My doctor appealed the decision and won.

Nice, who was your insurance provider and how long did the appeal process take?

PokMan845 wrote:I was initially declined as well. The reason was, I haven't tried Vacuum Pump or Muse. My doctor appealed the decision and won.

You may need to get your doctor to write a letter to them explaining why it is medically necessary. They are good at embellishment.

Larry

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

hturner12 wrote: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.

It is within the doctor's purview to make the case for medical necessity. If he did his job right during pre-authorization you will be fine.