When it comes to undergoing a medical procedure, cost matters. Understanding those costs, along with your insurance benefits and coverage options, can help you be prepared. For tips and guidance on next steps, select the option below that best aligns with your current situation.
I have commercial insurance
Many insurance plans provide coverage for incontinence treatments if you meet the criteria for being a medically necessary treatment. Your doctor can help you understand these criteria.
Your specific insurance plan and your physician can help you confirm if your insurance covers the male sling procedure. Your physician will review your coverage details during the benefits verification process.
While prior authorization for male slings does not guarantee that the procedure is covered, some insurance plans require it prior to the procedure.
If coverage for male slings is excluded, you will have the option to file for an exception.
If you prefer to appeal an exclusion with your insurance plan directly, reach out to your insurance representative and ask for instructions on how to submit the appeal request.
Be ready to provide supporting documentation that demonstrates the medical necessity of the procedure, which may include medical records, lab results, and notes from your urologist and other physicians such as your primary care physician.
You also have the right to appeal if your prior authorization request is denied.
Appeals give you the opportunity to present additional information, such as medical evidence or documentation, to support the necessity and appropriateness of the requested service, with the goal of securing coverage. Know that each insurance company can have multiple levels of appeals.
We have created a checklist to help guide you and your physician’s office in sending a complete and thorough appeal request to the insurance company: Appeals Checklist
You can also find helpful information on the Medicare website: How do I file an appeal?1
Depending on which state you reside in, you may have the option to utilize the Consumer Assistance Program. This tool also has quick access to State Insurance Boards as sometimes appeals to coverage can be external.
In addition, our Reimbursement and Benefits Team can assist you and your physician with the appeals process: 1-855-230-7611.
I have Medicare / Medicare Advantage
- Medicare Part A: This provides coverage for inpatient hospital care, skilled nursing facility care, hospice care, and some home health care services.
- Medicare Part B: This covers certain doctor’s services, outpatient care, medical supplies, and preventive services.
Medicare typically covers medically necessary procedures, including incontinence treatments, when deemed appropriate by a healthcare provider, without requiring prior authorization (obtaining approval from the insurance company before certain procedures can be covered).
A male sling procedure is typically performed under outpatient status. That means it will likely be covered by Medicare Part B, where your responsibility would be 20% of your cost of care. If you have supplemental insurance, you may have the additional 20% coinsurance covered by the secondary plan.
Medicare Advantage plans are a little different.
These managed Medicare plans are offered through private insurance companies approved by Medicare. These plans may have policies for prior authorization (approval from the insurance company before certain procedures can be covered) or pre-determination (confirmation of coverage before a procedure is performed, to allow patients and providers to understand coverage details in advance and anticipate potential out-of-pocket costs).
Costs and coverage for incontinence treatments under Medicare Advantage plans can vary depending on the specific plan. These plans have to cover at least what original Medicare covers; however, unlike original Medicare, these plans may place restrictions on coverage such as prior authorization.
You can visit the Medicare website to learn more about what Medicare covers,2 and download the Medicare and You handbook3 (PDF) for a detailed review of Medicare coverage.
It's essential to review the details of your plan to understand what is covered and any associated costs. Please consult with your healthcare provider and insurance plan to clarify coverage options and eligibility criteria.
I have Medicaid / Managed Medicaid
In other states, Medicaid provides coverage for medically necessary procedures, including male slings, for eligible individuals. Of the states where Medicaid does provide coverage for male slings, some may require prior authorization (approval from the insurance company before certain procedures can be covered).
In some states, Medicaid may cover the male sling itself but not necessarily associated costs such as facility fees or surgeon fees.
Please consult with your healthcare provider and the Medicaid program to understand coverage details and eligibility criteria.
I am paying without insurance
First, find out how your physician charges for their services.
- Many physician’s offices will offer self-pay options that may save you money.
- Having your procedure at a surgery center instead of a hospital may result in lower facility costs.
Next, consider exploring any additional savings and credit options to help you balance the costs most effectively for your situation.
You can save money in your HSA account before taxes and use the funds to pay for eligible healthcare expenses. This may include healthcare expenses your plan doesn’t cover.
Healthcare Credit Cards can provide an option for payment when you need health care services or procedures and can’t pay for them right away or the services and procedures you seek may not be covered by insurance.
This option allows you to get the treatment you need without delay. The card issuer pays the charges up front, while you can pay a little bit each month to get the necessary treatment while being able to manage the expense.
Various companies offer healthcare credit cards. If you would like to pursue paying for your procedure with a healthcare credit card, ask your physician if this may be an option.
Frequently asked questions
“Medically necessary” refers to healthcare services or treatments that are deemed essential to diagnose, treat, or manage a patient’s medical condition or symptoms.
For insurance companies, determining medical necessity helps control costs by ensuring that coverage is provided only for services that are essential for a patient’s health.
For patients, it’s important because many insurance plans, including some Medicare Advantage plans, will cover a male sling if it is deemed medically necessary by your healthcare provider.
A male sling may be considered a medically necessary treatment for you depending on the reason for your incontinence.
This process requires healthcare providers to obtain approval from the insurance company before performing a specific treatment, procedure, or prescribing a medication.
It ensures that the proposed service meets the insurer’s criteria for coverage, including medical necessity and appropriateness.
Some insurance plans, including some Medicare Advantage plans and Medicaid coverage in some states, may require prior authorization request before providing coverage for a male sling procedure.
There are a few reasons why your health plan may deny your proposed treatment, including:
- Services are not considered medically necessary or appropriate in a specific healthcare setting or level of care
- The health plan considers the treatment to be investigational, experimental or unproven
- The service requested is not a covered benefit under the plan
You have the right to file an appeal. This is when you ask for a full and fair review of the decision, aiming to overturn the denial and obtain approval for the procedure. Insurance plans often have multiple levels of appeal.
Appeals give you the opportunity to present additional information, such as medical evidence or documentation, to support the necessity and appropriateness of the requested service, with the goal of securing coverage.
This checklist can help guide you and your physician’s office in sending a complete and thorough appeal request to the insurance company: Appeals Checklist
If your state has a Consumer Assistance Program, they may also help file an appeal on your behalf.
In addition, our Reimbursement and Benefits Team can assist you and your physician with the appeals process: 1-855-230-7611.
Need help navigating the process?
Talk to an expert.
Navigating insurance benefits and coverage options can feel overwhelming. If you have questions about insurance coverage, our Reimbursement & Benefits Support Team is here to help. We’re available 9am-4pm CST. Give us a call today.
Find a local doctor
If you are ready to talk to a doctor about the possibility of receiving a male sling, use our physician directory to find a qualified urologist specializing in incontinence near you. They can answer your questions and help you take the next step toward taking back control of the lifestyle you want to live.
References
- How Do I File an Appeal? Medicare.gov. https://www.medicare.gov/claims-appeals/how-do-i-file-an-appeal. Accessed June 2024.
- What Medicare Covers. Medicare.gov. https://www.medicare.gov/what-medicare-covers. Accessed June 2024.
- Medicare and You Handbook. Medicare.gov. https://www.medicare.gov/publications/10050-Medicare-and-You.pdf. Accessed June 2024.