Insurance coverage

[Happy Toy]

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

I have Kaiser, will be implanted on the 26th. I checked on the co-pay, it will be $250 for the surgery. I know there will be some follow up costs, office visits for me are $20. So all and all not bad for a $30K surgery! Check with your financial department of Aetna, they should be able to tell what the cost will be. I would think a large company like that would cover it. Good luck with that and hope you have the surgery. From all of the feedback here on FT I'm sure I am doing the right thing.
Andy

[MK1965]

Thanks Andy,
If you feel you’re doing right thing then absolutely, you are doing right thing for yourself. I am of the opinion that every ED sufferer deserves the best, whatever his best it is ( implants, injections etc)
Wish you all the best for your procedure in near future.
MK

[David_R]

If my insurance does not cover implant

I understand that some doctors' office staff will call your insurance on your behalf to argue for you. If the insurance company covers breast reconstruction surgery after a mastectomy -- something that is not life-threatening but which is needed to improve life -- they will argue that the same should be the case for men and penile implants -- something that is not life-threatening but which is needed to improve life.

[Randy461]

Currently 2 years post RP, spared nerves on one side but not the other. I am starting to look into an implant. Use tri mix as well as bi mix with so so results.
I have employer provided Aetna Choice POS II insurance. I made 1 call to them with 3 dx codes including Peyrones as well as post RP ED. Was told they don’t cover the procedure.
Do any of you that had an Aetna paid procedure know the dx codes that were submitted for approval? Also for those still in the work force, how long out of work for the procedure? My job is somewhat physical so I would that would impact return to work time.
Any information is greatly appreciated.

[MK1965]

Currently 2 years post RP, spared nerves on one side but not the other. I am starting to look into an implant. Use tri mix as well as bi mix with so so results.
I have employer provided Aetna Choice POS II insurance. I made 1 call to them with 3 dx codes including Peyrones as well as post RP ED. Was told they don’t cover the procedure.
Do any of you that had an Aetna paid procedure know the dx codes that were submitted for approval? Also for those still in the work force, how long out of work for the procedure? My job is somewhat physical so I would that would impact return to work time.
Any information is greatly appreciated.

Randy,
I have same insurance as you, Aetna Choice POS II thru my employer.
My implant last year was mostly paid by insurance with my out of pocket $1450.
Since you had RP, for prostate Ca removal, this is valid reason and qualifies you for coverage unless your employer strictly stipulated that.
We have one member here who is fighting against sex discrimination with his insurance company which denied coverage or his implant regardless of ED after prostatectomy.

Here are my ICD10 codes that were submitted to insurance:

N52.02 Corporo-venous occlusive erectile dysfunction
N52.31 Erectile dysfunction following RP

And CPT code for surgery:

54405 - Insertion of multi components penile prosthesis including placement of pump, cylinders and reservoir.

I hope this might help you and you can compare your doc codes against my codes.
Good luck,
MK

[Napier]

Medicare. I paid $93 co-pay as my usual co-pay is about $30. Medicare paid the balance of $46,000. Apparently, it all went very smoothly. I told the doc i had medicare, and he went to work on me about a week later.

[newbie443]

Can you help me choose a good insurance company in 2021? I am very tired of paying for very expensive sessions with a doctor and dentist. I hope you can help me!

Welcome to the site. Insurance in the US is state controlled so you might put in your location. I know my home state of KS regulates who can and cannot sell health insurance in my state. And employers policies can have policies with no coverage for some things.

I buy my own health insurance from BCBSKS. It is the same plan that is offered on the states health care market place. It is a Gold plan and the most expensive premium of the plans they offer and costs me $1175.00 a month. With a $1500 deductible and $3500 max out of pocket. They have other plans just over 1/2 the premium I pay but with much higher deductible and max out of pocket. It is an EPO plan and only has coverage in most of the state of KS. Other plans with out of network coverage in my state with another insurance company is approx.. 2K a month.

8 months before I can start Medicare. I figure a good supplemental plan will be 1/2 or less what I pay now and I hope to have better coverage.

[October26]

My UnitedHealthcare specifically excluded the procedure but when the doctor's office was denied, I prepared a carefully worded appeal and it was authorized. The implant with night in the hospital cost zero to me.