Help: Procedure Rejected by Insurance Carrier

[GLE Man]

Hello everyone,

This is my first post. The first thing I want to do is tell everyone how much I enjoy this site. It is extremely informative and I feel as though I have already made some new friends since I joined nearly a month ago. I had a situation that I want to share with everyone as well as solicit your opinions and advice.

I was scheduled to have implant surgery today but found out just last week, less than a week prior to the procedure, that my insurance carrier, Aetna, was not going to cover it. I was of course very disappointed and pissed off. Since then, my doctor did a peer-to-peer review and seems to think it will be approved once new required information is submitted. Even if approved, my doctor’s office says the next availability is not until March of 2021. As you all can imagine, after waiting and anticipating this for months already, another 3 months wait seems like an eternity. I am the type of person that needs a plan B, C, and D if necessary and this is where I need your input and advice on the following:

1) What carriers do you all know for sure will cover the procedure (multi-inflatable penile prosthesis)? The CPT code is 54405
2) Should I look into switching insurance carriers?
3) I don’t have the $22,000-$26,000 on hand, so what are the best funding methods for out of pocket payment that is reasonable and affordable?
4) If the procedure is approved, or other funding secured, should I wait until March or consider another doctor?

Thanks for reading this rather long post and I appreciate any and all advice you can provide. Feel free to respond to me personally via private message.

GLE Man

[ViaSwiss]

If you do end up opting for an out of pocket cost you can use this thread to look at that cost for some of the more common surgeons

viewtopic.php?t=12950

Additionally, you can use surgeo.com to use their service for out of pocket. 50% of the surgeons listed there I do not know how well they do, but the added benefit is the insurance it provides in case you encounter complications.

AMS has a financial program where they will finance a 5 year plan for out of pocket costs. Coloplast does not do any plan like this so you'd have to opt for CX or LGX and not Titan.

[Agfa13]

Well, if it will save your sanity by saving you the $$$, AND it gets approved, wait until March.
By this time too, you will more than likely have been inoculated against Covid.

Since March is a long way off, and you can finance for AMS, look for another Dr./appt.
Now you know what to ask, what you have to offer, and you have your plan B, C, and D.


BTW...and FT. Be sure to let us know what is happening.

[GLE Man]

Let me provide you all with the latest update: The insurance carrier made take a blood test to test my testosterone level. I did that. Seems my testosterone is low (imagine that I'm nearly 60 y/o) and they are wanting me to do/consider testosterone recovery treatment. I have another test for they want me to do. My doctor is convinced it my ED is not caused by low testosterone and and says he'll do a peer-to-peer if necessary.

GLE Man

[Old Guy]

Let me provide you all with the latest update: The insurance carrier made take a blood test to test my testosterone level. I did that. Seems my testosterone is low (imagine that I'm nearly 60 y/o) and they are wanting me to do/consider testosterone recovery treatment. I have another test for they want me to do. My doctor is convinced it my ED is not caused by low testosterone and and says he'll do a peer-to-peer if necessary.

GLE Man

Most insurance companies want to see prior history of what you have already tried for ED. If you've used Viagra or Cialis or injectable drugs with no help that should be #1 reason why they should consider coverage. Low T does not, as far as my research shows, does not cause ED.