Insurance Denied Coverage for Implant

[barney1962]

So disappointed. Was scheduled for inflatable implant on December 20th and just got a letter from insurance saying it’s not a covered service. Thing is it’s listed in benefit booklet as covered. Just sent a appeal letter but it’s frustrating. Been suffering with Ed for over 20 years and tried the pump, pills, and injections. All insurance plans should cover this.

[Floridaspeedo]

Keep working with the doctor. Sometimes it takes two or three tries to get it approved

[Old Guy]

Definitely appeal it. Rep from my insurance called and tried to talk me out of it. Took two tries for surgeon's billing office to get me approved.

[Lost Sheep]

So disappointed. Was scheduled for inflatable implant on December 20th and just got a letter from insurance saying it’s not a covered service. Thing is it’s listed in benefit booklet as covered. Just sent a appeal letter but it’s frustrating. Been suffering with Ed for over 20 years and tried the pump, pills, and injections. All insurance plans should cover this.

Old guy mentioned it, but did not suggest it directly, so I will. Ask your surgeon's office for help in pursuing the appeal. You may want to enlist the aid of your firm's Human Resources department as well. They have an interest in making sure the insurance company honors their promises and if the insurance company feels they may lose the contract with your employer...well that hits them in their (pocketbook) incentive soft spot.

[treetop]

Can we ask what insurance company?... Aetna, BC/BS, Medical, etc.

[JetAirliner]

So disappointed. Was scheduled for inflatable implant on December 20th and just got a letter from insurance saying it’s not a covered service. Thing is it’s listed in benefit booklet as covered. Just sent a appeal letter but it’s frustrating. Been suffering with Ed for over 20 years and tried the pump, pills, and injections. All insurance plans should cover this.

Old guy mentioned it, but did not suggest it directly, so I will. Ask your surgeon's office for help in pursuing the appeal. You may want to enlist the aid of your firm's Human Resources department as well. They have an interest in making sure the insurance company honors their promises and if the insurance company feels they may lose the contract with your employer...well that hits them in their (pocketbook) incentive soft spot.

Agreed with Lost Sheep …. In my case I was denied three times (Cigna) before getting approved and I am 10 weeks post op … In my case to make sure everyone had skin in the game- I had my attorney send a letter to my insurance company, insurance broker, while copying in my HR department with a letter from my surgeon regarding the appeal… Everything was approved 3 weeks later … Keep fighting as the insurance companies are banking on individuals giving up

[barney1962]

This was Anthem Blue Shield. I’ll see how the appeal goes. Doctor didn’t seem to be interested on the appeal bu I’m not going to let it drop. Only thing is I work for a small company and wanted it to stay under the radar with the coworkers. Might have to push it though.

[Time2Change]

Make sure your doctor is submitting the appeal with the correct codes.

Ultimately, that's what needed to be corrected in order to get approval from my insurance company.

[Bent Ben]

This was Anthem Blue Shield. I’ll see how the appeal goes. Doctor didn’t seem to be interested on the appeal bu I’m not going to let it drop. Only thing is I work for a small company and wanted it to stay under the radar with the coworkers. Might have to push it though.

Anthem is usually pretty good about this. Is your insurance employer sponsored thru the state exchange? If so keep appealing.
If it is straight employer sponsored then you may need to reach out to your employer’s HR department and have them turn on coverage for “sexual disfunction”. Ask your doctor for the insurance code they are submitting and give it to HR.
Many times the insurance company is just following thru on the dictates of the employer. At the same time the employer will decline coverage en masse without an understanding of what the insurance companies are listing under specific codes and titles. I can see where a benefits admin says no to “sexual health” thinking they'll be paying for recreational Viagra and non-reconstructive breast jobs. The insurance companies will put surgeries like ours or breast augmentation after cancer in there knowing the admins will decline coverage because of the aforementioned.

Stay diligent

[Lost Sheep]

Yes to the prior posts. Health insurance is not for enhancement of a natural function, but RESTORATION of a lost function or reconstruction after an injury or disease is definitely in the intention of most insurances. Approach the appeal with that embedded in the text.