Agfa13 wrote:Biker60, you are right to distinguish about your body dysmorphia and an implant.
Like cialis and viagra, the only thing people see are the words, not what is behind them, no pun.
Cialis can also be used for blood pressure treatment, but because the 1st thing that comes to mind when word is said is erection, it is not covered.
Have doctor resubmit claim and in no way, shape or form, use the word implant by itself in describing your dysmorphia.
I would suggest asking if the pain from the peyronie's or potential for penile damage (which should be covered by insurance, so the company DOES have a vested interest in an implant as a preventative, prophylactic procedure) would lend support for your appeals.
That is what happened when I went to a the high volume gods, they sent in a pre determination without medical need. Aetna indicated in the letter, cannot cover because if exclusion. But the letter, mentioned, sending in more details to prove otherwise. I latter found out Aetna had no diagnosis code, or med records at all. I found it strange when High volume, long distant implant surgeon canceled my ultra sound. That is a tool to diagnose PD, and ED. So bottom line he was not giving me the diagnoses, he was providing implants. He accepts my say so, that I had PD. Well moving forward, new surgeon has primary diagnoses as PD and ED. Implants for PD are only recommended with ED as well. Or that is a criteria . I think Aetna requires 1 cycle of xiaflex as well. So regardless, I am going for it. My Aetna is self funded and does not require prior auth. It the employer is is excluding it. But not no mention off PD, so I need this to be a claim so I can be appealed if denied. Aetna itself sees implants as a med nec in PD. I want a exclusion exception and that is what Aetna said to request. I am having this done at a Hospital that is part of an Ivy league University system. Surgeon is Dept chair of Urology. According to health grades, he does penile implants 79% more then his peers. He is also an employee, so the money is not the driving force for the procedure. He also, has published 17 articles in various journals in the field of urology. Bottom line, I have 4 appeal levels, the last being my employer. So, in order to appeal, it has to be a claim. Either way, I saved my 30K. Maybe things will go my way, and this will be covered and 2020, starts off on a positive note.
