“Does Medicare cover penile implant surgery?”

Yes – Medicare or Medicare Advantage Plan provides coverage for penile implant surgery and all other Coloplast devices, as long as they meet criteria for being medically necessary. Your doctor should be able to help you understand these criteria. Patient payments are estimated between $2,500 and $3,000 unless there is a secondary or supplemental plan.

Here are some general criteria standards:

A penile implant 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.

Traditional Medicare does not require any authorization for these procedures, but if you have Medicare Advantage coverage, your physician may need to get approval before scheduling your surgery. Occasionally, Medicare Advantage plans may be reluctant to cover these procedures, but this is usually straightforward to resolve as they are required by Federal guidelines to cover any procedure which Traditional Medicare does.

Penile implant procedures are normally performed under outpatient status. This means they will be paid by your Medicare Part B coverage. If you have met your deductible for the year, and do not have Supplemental Coverage, you will owe 20% of all allowed charges. At a minimum, there will be charges from your surgeon and from the facility. There may be charges for other tests or services associated with this procedure.

The Medicare rates for services vary by region of the country. Medicare also reimburses differently to a Hospital (outpatient) or an Ambulatory Surgery Center (ASC). Here is an example of what your financial responsibility may be, based upon the national average Medicare rates. (Please keep in mind this is only an estimate. Actual charges may be higher or lower, and may include services not accounted for here.)

If you have questions about your Medicare or Medicare Advantage coverage, please contact your Medicare or Medicare Advantage member services department. A physician’s office may be willing to answer additional questions as well.

DISCLAIMER: This information, is general in nature, and does not cover all payers’ rules or policies. This information was obtained from third party sources and is subject to change without notice as a result of changes in reimbursement regulations and payer policies. This information represents no promise or guarantee by Coloplast regarding coverage or payment for products or procedures by CMS or other payers. Providers are responsible for reporting the codes that most accurately describe the patient’s medical condition, procedures performed and products used. Providers should check Medicare bulletins, manuals, program memoranda, and Medicare guidelines to ensure compliance with Medicare requirements. Inquiries should be directed to the appropriate other payer for non-Medicare coverage situations.

This information is intended for informational purposes only. The final decision for coding and billing is the responsibility of the provider. The existence of codes does not guarantee coverage or payment. Coloplast Corp. makes no warranties or guarantees, expressed or implied, concerning the accuracy or appropriateness of this information for any particular use and this information is not intended to provide coding direction or advice.