Insurance Coverage Loopholes?

[atlguy82]

Longtime lurker. First time poster. My partner and I are working toward the next step of an implant. However, my corporate insurance states that code 54405 (assuming this is the correct code) is not covered, full stop, unless it's for gender affirming surgery. I called my insurance provider and the lady was very nice and advised me that it is on the not covered list, but that we can try to have the doctor submit medical records to see if it would be covered. I got the sense that she was just trying to be polite, but is it possible there's a loophole? We've tried pills, injections and pumps to no success, so this is the logical next step.

Any suggestions for supplemental insurance? We are both well under the age of medicare coverage.

[easymoney]

Seems like if you went through the steps to "cure" ED then an implant would be the last step ..if dr. summitted proper paperwork I would think it would be covered ..

[duke_cicero]

I struggled with my crappy insurance and went the self-pay route and used a medical loan from a bank with favorable terms. I have no information for you unfortunately but am very interested in finding out how things work out for you and am hoping for the best for you. The frustrating thing about all of this is that fixing ED for biological males is absolutely gender-affirming care. This needs to be addressed.

[stmcknig]

The go to denial is medical necessity and usually they have to quote what guidelines they based their decision on. As a diabetic and heart attack patient having failed with oral and injections medication I used ChatGPT to use their guidelines against them with my history and medical profile to draft and submit an appeal. Which was successful. Then of course I was crapping myself about going through with it but with a 90 day pre authorization ticking I bit the bullet. So far pleased with the smooth process and looking forward. Should probably have quit procrastinating with the injection for so long. Much emotional relief…

[duke_cicero]

The go to denial is medical necessity and usually they have to quote what guidelines they based their decision on. As a diabetic and heart attack patient having failed with oral and injections medication I used ChatGPT to use their guidelines against them with my history and medical profile to draft and submit an appeal. Which was successful. Then of course I was crapping myself about going through with it but with a 90 day pre authorization ticking I bit the bullet. So far pleased with the smooth process and looking forward. Should probably have quit procrastinating with the injection for so long. Much emotional relief…

Oh wow. This is fascinating. I think in my insurance there is an outright exclusion for penile implants. What is the situation with yours?

[equusAz]

I worried about this NON-Stop before my surgery - that I would get the surgery or to the hospital and it wouldn't be covered (United Health Care) It was. Not all insurance companies are the same - and IMO this is insane. Some cover it, some don't, some require you to go through the rigamarole of all other options first.

[JohnDoe]

I am strongly considering getting an implant. The insurance verbiage is truly mind boggling though. I have great insurance through Blue Shield HMO of California, but they clearly state that implants are not covered unless medically necessary. "Medically necessary" can be interpreted so many different way of course. I have two cysts on my testicles that need to be removed. I'm hoping an implant can be combined with the same surgery, and covered by the insurance. If not, I will simply pay out of pocket.

[LastHope]

Just to get an idea, I looked at a journal paper that studied insurance claims for this procedure. They studied the percentage of insurance approvals in Miami, Florida region for submitted claims for IPP between January 2016 and December 2017. Here's the list. This may not correlate 100% with year 2024/2025, but hey...maybe there's a historical pattern to note.

Medicare: 100.0%
Coventry: 100.0%
United Healthcare: 70.0%
Molina: 65.5%
Humana: 62.5%
Blue Cross Blue Shield: 56.3%
Sunshine Health: 50.0%
Aetna: 36.4%
AvMed: 15.8%
Cigna: 14.3%
Magellan: 0.0%
Medicaid: 0.0%

Commercial Insurance Overall: 52.0%

Source:
Commercial Insurance Coverage for Inflatable Penile Prosthesis at a Tertiary Care Center
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6675033/
Urology Practice Journal, 2019 May

The general consensus among the surgeons I've consulted is that Humana, UHC, and BCBS are generally okay, but Aetna and Cigna can be a pain in the ass. They may give you the runaround with appeals and require extensive proof that you've tried every other therapy.

[LastHope]

I don't see Kaiser Permanente mentioned here. Anecdotally, I know they are not into routine denials for this procedure like Cigna or Aetna. However, the biggest challenge with Kaiser is finding a Kaiser-affiliated, high-volume or atleast a medium volume center of excellence surgeon in some states.

[jssherrard]

My insurance (Anthem BCBS) fully covered my implant (minus the 2,000 deductible), but only after ALL other methods had failed. My urologist thoroughly documented the previous non-surgical failures and subsequently provided that information to my medical insurance. At that point, we finally got the okey-dokey to go ahead. I know other men have had similar experiences. Work with your urologist to exhaust other methods, then you’re more likely to get approval.