“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.
- 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.
- 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.
Titan® and Titan® Touch Inflatable Penile Prosthesis – Important Safety Information
A penile implant, also called a penile prosthesis, is concealed entirely within the body to address erectile dysfunction (impotence). The implant requires some degree of manipulation before and after intercourse to make the penis erect or flaccid.
The Titan and Titan Touch Inflatable Penile Prosthesis is indicated for male patients suffering from erectile dysfunction (impotence) who are considered to be candidates for implantation of a penile prosthesis.
The Titan and Titan Touch Inflatable Penile Prosthesis is contraindicated in patients who have one or more of the following: (1) Patients with an active infection present anywhere in the body, especially urinary tract or genital infection. (2) Patients with a documented sensitivity to silicone. (3) Patients with unresolved problems affecting urination, such as an elevated residual urine volume secondary to bladder outlet obstruction or neurogenic bladder. (4) Patients unwilling to undergo any further surgery for device revision.
Implantation of the device may make latent natural erections, as well as other interventional treatment options, impossible. Men with diabetes or spinal cord injuries, as well as immunocompromised patients, may have an increased risk of infection associated with a prosthesis. Implantation of a penile prosthesis may result in penile shortening, curvature or scarring.
Removal of an implanted prosthesis without timely reimplantation of a new prosthesis may complicate subsequent reimplantation or may make it impossible. MRI quality may be compromised if the area of interest is in the exact same area or relatively close to the position of the Titan, and Titan Touch IPP. Be sure to consult with your physician. Patients should discuss all available treatment options and their risks and benefits with their physician. Health conditions which hamper sexual activity, such as severe chest pain (angina), may prevent successful use of this device. The prosthesis should not be implanted in patients who lack the manual dexterity or strength necessary to operate the device. Trauma to the pelvic or abdominal areas, such as impact injuries associated with sports (e.g., bicycle riding), can result in damage of the implanted device and/or surrounding tissues. This damage may result in the malfunction of the device and may necessitate surgical correction, including replacement of the device. The device may be used in the presence of Peyronie’s Disease.
Penile implants are surgical solutions requiring a healing period that have risks associated with surgery such as scrotal swelling, auto-inflation, discomfort, angulation/curvature, swelling (edema), device malfunction, chronic pain, difficulty with ejaculation, transient urinary retention, fever, migration, patient dissatisfaction, infection at surgical site or wound, deflation, swelling of clotted blood or clear fluid (hematoma/seroma), wound leakage, bleeding, delayed wound healing, narrowing of the opening of the foreskin (phimosis), sensory loss, cylinder malfunction, formation of thick tissue (fibrous capsule formation), over/under inflation, erosion, scrotal reddening (erythema), genital change, and inguinal hernia.
This treatment is prescribed by your physician. Discuss the treatment options with your physician to understand the risks and benefits of the various options to determine if a penile implant is right for you.
Caution: Federal law (USA) restricts this device to sale by or on the order of a physician.