Getting Aetna insurance through my job, is implant covered?

[EricDraven]

My new job is getting health coverage by Aetna. I’m trying to use Dr Hakky in Atlanta. I’ve got 10 years of documented history of ED with the VA. Dr. Hakky’s office said it wasn’t normally covered by insurance.
How do I proceed with trying to get Aetna to cover the procedure?

[Old Guy]

More than likely a new Aetna policy will have limitations, meaning I doubt they will pay for an elective surgery in the first year or two. If you've been to the VA I'd search for a doc there. Many vets have had theirs done at the VA and had good results. Hopefully some guys who been there will chime in.

[EricDraven]

Old guy, the VA is scheduled to do the surgery in November. I met the very young and inexperienced surgeon and had 2nd thoughts

[Floridaspeedo]

My new job is getting health coverage by Aetna. I’m trying to use Dr Hakky in Atlanta. I’ve got 10 years of documented history of ED with the VA. Dr. Hakky’s office said it wasn’t normally covered by insurance.
How do I proceed with trying to get Aetna to cover the procedure?

I have Cigna but the same type of big insurer. Each insurance company has many many policies so it will depend on the type of plan your employer paid for and which one you signed up for.

I went to 2 Dr's the first got the implant approved immediatly even after his office staff told me Cigna doesn't cover it.

The 2nd doctor who I went with took a couple of weeks of back and forth. My point to Cigna was you approved the first doctor and I am fighting to get the same procedure approved with another doctor but the patient is the same. My ED didn't magically go away.
Just crazy but they finally approved it but it took work.

The key is your doctor needs to push for it and of course they would prefer you pay cash verus you using insurance.

[bionicbrother]

Let me share my experience. I have Aetna insurance through my employer too. I went through with my doctor and they pre authorized it ( written authorization). I went through the procedure in May and in July I got a bill for $21k(from my provider - these are not deductibles this is the cash price from my provider) because my insurance declined to pay the provider!!! Fast forward to September my provider is still working with the insurance to get them to pay and honor their commitment.. No way I am gonna pay anything to the provider other than my coinsurance and deductibles

So insurance folks can be very tricky especially those with the employer as they have more exclusions.. Usually implants are excluded.. The only thing you can do is to get your doctor to present it in a way that would make insurance approve it ( your doctor should know this all- the coding, details to provide etc).. But even after that your insurance declines you can try to appeal the decision..

[Merknaut]

I am currently going through the process of trying to get an exception/appeal pushed through. I have Cigna through my employer, but my employer is a small company and is "fully insured" not "self-insured." I was rejected by Cigna when my doctor submitted the request back in February.
I went to Boston Scientific and found that they had a program to help navigate the appeal process. I am convinced that they don't have all the correct information to begin this process because they had me address the issue with my employer. I submitted the rejection document and the letter to my HR director and she didn't know what to do with it and sat on it for months.
Finally I am working with an HR specialist who has referred me to an advocate with USI Benefits Resource Center. The rep there tried to tell me that if it is a contract exclusion that there is very little chance that they will make an exception and that he and his supervisor were of the opinion that I shouldn't even try. I told him to take what I have and submit it to Cigna. That was three days ago and I have no confirmation from him whether or not he has proceeded.
At this point I am just about ready to take things into my own hands and just deal directly with Cigna. It is clear that my employer's HR department is clueless and doesn't know how to help in any way and will not. The people at USI seem determined to do as little as possible.
I am frustrated because I know that getting the implant is really what I need but it seems like I am being blocked at every turn. Pretty sure that Cigna has the CPT code for penile implant excluded from all their plans with small to medium sized employers. Not sure what to do to get this moving forward in some way.
Not sure if posting in this thread is going to get me any help.

[Floridaspeedo]

@Merknaut

I have Cigna as mentioned above. The implant was not excluded but it wasn't included either. My Dr kept pushing and it was attached to "Gender reasignment." No I did not have my gender reassigned but it was included in that section.

I also went to 2 Dr's. The first Dr got it approved almost innediately and I expect because he was a high volume Dr he knew what to say.

The 2nd Dr who I went with had to do a lot of back and forth to get it approved. I expect because IPP was not his total practise.

In the end Cigna did approve but it was a fight.

I never even touched HR. They are clueless.