Last minute insurance issues With Dr Kramer

[jersey58]

I am new to this board but have been lurking here for some time. After much research, I have implant surgery scheduled on March 26 with Dr. Kramer, and just received word that Cigna has denied coverage (Kramer is in-network).

In the way of background, I have had ED issues for 25+ years (I'm very healthy otherwise). I'm currently 58 and started with the oral medications (Viagra, Cialis, etc in my 30s). By the time I reached my early 50s, I could no longer get and sustain an erection with oral meds. In 2011 I began seeing a urologist who did an ultrasound, diagnosed the venous leak, and put me on tri-mix. Tri-mix worked well initially. In the past 2 to 3 years I have developed peyronies I believe from the injections, . I have plaque on the dorsal side causing an upward curve and also have a large plaque deposit on my left side causing a bend to the left. Tri-mix has become less reliable, and I have moved to a higher dose of a stronger mix. In the past where I would be sure I would have an erection for at least an hour, now it sometimes dissipates within 10 to 15 minutes. I also have some discomfort and occasional pain during intercourse which is increasing over time.

I scheduled the surgery three months ago with Kramer's office. I gave them complete information about my condition as well as a release for my urologist and they said they would apply for Cigna precertification. Cigna first sent Kramer and me) a letter indicating that they needed additional information to determine if the service was medically necessary. Two days ago I saw on my Cigna website that they have denied precertification for “ED due to arterial insufficiency”. There is no mention of peryonies, which I feel is the bigger issue for me. (I have pointed this out to Danielle and Leslie Thomas).

I am now less than three weeks away from my scheduled surgery with no insurance approval. For those who have navigated this insurance maze, what is my best course of action at this point? I feel like peyronies must be listed as the primary reason for the procedure. Dr. Kramer has never examined me. Even my urologist has not actually seen my erection with peyronies, other than cell phone pictures I have provided. Is there a way to salvage this and keep this procedure on for March 26 or do I have to pull back and take another approach? I have spoken to Danielle who has asked me for “additional medical records which show I have tried and failed pills, pumps, and/or injections” which I feel my urologist’s records should provide. Do I need to cancel this procedure and go back to my urologist to build a case and then reapply to Cigna? Can I make an appeal directly to Cigna? I need to make a decision on whether this operation is happening this month, and feel like Kramer's office staff is not really give me the support I need to get insurance approval (although he is great and very responsive).

Any advice would be greatly appreciated.

[Waynetho]

Jersey, first I'd suggest reviewing you insurance company's policies on implants. If the insurance is with your employer, you may need to check your employer's policies too.

It may be that Dr. Kramer only submitted the claim for sexual enhancement but you have an ace in the hole, so to speak. You have Peyronie's disease. If Kramer didn't submit to insurance on the grounds of correcting physical damage, a.k.a., Peyronie's, that may be why it was denied.

My insurance through my employer doesn't cover implantation for enhancement but recognises and covers it for Peyronie's because it's the go-to and most effective treatment for that issue.

Because my insurance covers Peyronie's related implantation and my doctor put down PD as one of the reasons, it was approved on the first attempt, unlike my UroLift that took three appeals to get approval.

[jersey58]

Thanks Wayne. I think you are right about needing to submit to insurance for correction of peyronie's. I don't know why they did not do that in the first place. Hopefully this can be resubmitted in time to get approved before March 26th, not sure how long the process takes.

[rdnkbiker]

Good luck Jersey Cigna did the same to me had a confirmation # everything last minute denied it I got stuck holding the bag of bills will pay until I die im sure hopefully you have better luck
jim

[disapointed2]

last year I was having trouble with my insurance and was not getting any answers as to the coverage being taken care of or not. After 10 different calls no answers.
I contacted Dr Kramer.s office and talked with them about my insurance. I really must say, Dr. Kramer has a terrific office staff. I left it all up to them. They took care of all of the headaches. Every thing was approved and I got my letter of authorization on August 25 of 2019. My surgery was August 20. LOL.
Call Dr. Kramer,s office and explain your concerns. I have a lot of faith in his office help.
Good luck to you.
Disapointed 2

[NeedleD]

last year I was having trouble with my insurance and was not getting any answers as to the coverage being taken care of or not. After 10 different calls no answers.
I contacted Dr Kramer.s office and talked with them about my insurance. I really must say, Dr. Kramer has a terrific office staff. I left it all up to them. They took care of all of the headaches. Every thing was approved and I got my letter of authorization on August 25 of 2019. My surgery was August 20. LOL.
Call Dr. Kramer,s office and explain your concerns. I have a lot of faith in his office help.
Good luck to you.
Disapointed 2

My URO (Dr. Levine, Rush Hosp Chicago) and Coloplast have upped the anti with my Ins co appeal. They both have escalated my approval.

[Biker60]

I had my surgery for Pd. Dr entered Pd. Unknown dr entered Ed. Aetna denied for Ed. Hospital billed wrong coding. My bill 43000. Lost 1st Aetna appeal, because unknown dr changed diagnosis. Told hospital they screwed up appeal and removed charges. So I don’t own anything until hospital resubmits. 1st appeal listed everything done for Peyronies. Denied on bases of sexual dysfunction. But they say they don’t pay for. But they paid 40k for xiaflex, and 10k for the plication durning implants. On 2nd appeal, I have 4. Under ERISA in can bring suit against Aetna at 3rd appeal. 4th appeal is my employer. A 5 hospital healthcare system. Found out since my surgery was done in Pennsylvania I am protected against crazy billing. If you have no insurance or under insured, hospital can only charge the Medicare rate. 17,000 is max in Pa for implants. So, worst comes to works, we can start negotiations at 25 cents on the dollar. Settle at $11500, maybe more. Only works when dealing with major hospital and Dr is an employee.

[jersey58]

Good luck Jersey Cigna did the same to me had a confirmation # everything last minute denied it I got stuck holding the bag of bills will pay until I die im sure hopefully you have better luck
jim

Hey Jim, what was the reason for last minute denial? That is messed up...

[jersey58]

last year I was having trouble with my insurance and was not getting any answers as to the coverage being taken care of or not. After 10 different calls no answers.
I contacted Dr Kramer.s office and talked with them about my insurance. I really must say, Dr. Kramer has a terrific office staff. I left it all up to them. They took care of all of the headaches. Every thing was approved and I got my letter of authorization on August 25 of 2019. My surgery was August 20. LOL.
Call Dr. Kramer,s office and explain your concerns. I have a lot of faith in his office help.
Good luck to you.
Disapointed 2

Hey Disappointed, do you remember who it was in Kramer's office who helped you get this approved? I'm having a hard time finding the right person to push this for me.

[rdnkbiker]

Sorry Jersey
haven't been on here in a while... they don't do any sexual disorder I which mine was beyond that still wouldn't help out I tried everything
Jim...