“I have commercial insurance coverage through my employer or I have purchased an individual plan.”
Most plans provide coverage for most Coloplast devices, as long as they meet criteria for being medically necessary. Your doctor should be able to help you understand this criteria, but these are some general standards:
- A penile prosthesis (Titan or Genesis) is considered a medically necessary treatment for erectile dysfunction if the patient has tried and found ineffective non-invasive treatments (drugs, injections and/or vacuum devices), and the dysfunction is the result of an organic rather than psychogenic cause.
In an effort to keep premium prices and other expenses manageable, all plans include some exclusions. Before planning a procedure, you need to determine if penile prostheses (implants) are covered by your plan. Be aware that exclusions for penile prostheses do occur. Your physician’s office staff will likely contact your insurance company on your behalf to check benefits. However, you may wish to contact them yourself to check on coverage and to ensure that you understand what your out-of-pocket expenses might be. You may also want to contact your employer for a copy of your summary plan description (or SPD) which will include those items/procedures considered to be excluded by your plan.
If you choose to contact your insurance company yourself, you’ll need to provide:
- Name of your doctor
- Name of the facility where the procedure will be performed and the expected date of service
- Procedure code(s) and diagnosis code(s) (your physician’s office should be able to provide this)
- If the procedure will be performed under inpatient or outpatient status (ask your physician’s office if you are uncertain)
You can call before you’ve collected all of this information, but the representative may not be able to completely answer all of your questions. Always note down the date, time, and name of the person you spoke to, along with any information they provide. Ask for clarification of any terms or abbreviations you do not recognize.
The main questions you need answered are:
- Is this procedure a covered benefit under my plan?
- Are both my physician and the facility in-network?
- Do I (or my physician) need to get prior authorization for this procedure? If yes, how do you go about this? If no, can we submit a courtesy pre-service review?
- What will my financial responsibility be? (deductibles, co-insurance, co-pay )
- Does my plan have an exclusion for this procedure?
The representative should be able to tell you what percentage of the costs will be your responsibility. There will be separate bills from (minimally) the surgeon and the facility. The representative may or may not be able to tell you the actual costs, as reimbursement rates can be subject to contracts.
If you are told that the procedure is not a covered benefit, do not hang up! Ask specifically why it is not covered, and if there is a process for you to appeal the exclusion. This may also be called a grievance or a dispute.
Ask that the relevant policy be sent to you, or determine where you can find it online. If possible, access to the full plan document rather than just the paragraph involved can be of great help in creating an appeal. The appeal can come from you, your physician’s office, or a representative that you designate to help on your behalf.
If you have already appealed, and it has been denied, carefully review the letter, there may be other appeal options available to you. Changing insurance plans or managing the costs of the procedure yourself also may be an option. For additional information, please refer to the “Uninsured” section.
Whether you are responsible for a percentage of covered costs or you are paying for the procedure yourself, be aware that your choice of physician and facility can affect your costs. Contracted insurance rates can vary between providers and facilities. In or out of network status also generally affects your costs. Do not hesitate to check all of your options. Some hospitals, surgery centers, or providers have co-pay assistance, or are willing to set up a payment plan. Keep in mind that you will receive a bill from (at minimum) the surgeon and the hospital or surgery center.
If you have any additional questions about your insurance coverage, please contact them directly or reach out to your physician’s office who may be able to offer additional support.