Insurance Coverage for Penile Implant (Prosthesis)

Insurance coverage is a significant factor in the decision-making process for many of our patients. That said, you will be happy to know that most commercial insurances (individual, group, and commercial), Medicare, and VA insurance may cover a penile implant when considered medically necessary. Every insurance company will have slightly different standards to determine whether they will cover penile implants.

A Note on Medical Necessity

Medical necessity can be a rather vague term that insurance companies use to give themselves flexibility in approving or denying coverage for a particular procedure. When it comes to erectile dysfunction, however, it is apparent that when medications and injections fail to offer appropriate relief and regain of function, there is a medical necessity for further treatment in the form of a penile prosthesis. However, as a member, it is crucial that you contact your insurance company to understand their coverage criteria. We will also assist you by verifying your benefits to help ensure you do not have any billing surprises after surgery. We encourage every patient to advocate for themselves by performing this essential preoperative due diligence.

These criteria for medical necessity are generally quite similar between companies, and Dr. Natale, as well as our billing office, will, of course, consider these factors when recommending further treatment up to and including an implant. Some possible criteria include:

• Confirming that the manifestation of your ED is a physical and not psychological concern.
• Documentation that ED has been a concern for an insurance-defined period.
• Non-surgical interventions for ED have failed or are not indicated in the patient.

Many insurance companies, but not Medicare or Medicaid, offer. Give us the opportunity to pre-authorize surgery, which adds a layer of security to coverage and gives our patients peace of mind.

Exclusions

Some insurance companies and plans may have an exclusion for penile implantation. Reading your plan’s documentation is essential to understand whether you have coverage or if penile implantation is excluded. Just because you have the same insurance company as a friend or family member that was covered does not necessarily ensure that you will also be covered. This, again, necessitates spending the time to understand your policy and speaking to our billing specialists.

If your policy excludes penile implantation, we don’t want you to be concerned. We encourage you to contact us to discuss the options for a cash payment or financing the procedure. The company that makes the implants we use, AMS/Boston Scientific, may also be able to assist with the cost. We do our very best to offer this life-changing surgery to as many patients as we can, even if they do not have insurance coverage.

If I’m Covered, Will I Incur Any Cost

In short, the likelihood is that there will be some cost associated with your procedure even if you do have coverage. There are a number of cost-sharing features of your plan that can include;

1. A copay is a fixed amount of money paid at each visit to our office and varies based on the procedure being performed.
2. A deductible is the amount of care cost you are responsible for before the insurance company begins to cover it.
3. The coinsurance is the percentage of the cost of care that you will be responsible for on an ongoing basis up to the out-of-pocket maximum.

The bottom line…depending on when you have your procedure and what other medical costs you have incurred to that point, your final cost may vary.

It is worth noting that your insurance company likely has a contract with in-network providers like us and the hospital or surgery center we employ. This usually means that your cost will be significantly lower than the “retail” price for the procedure or hospital/surgery center.

For Your Reference

Diagnosis codes are used by doctors and insurance companies to label the diagnosis and guide reimbursement for treatment.

• F52.21 Male erectile disorder
• N52.01 Erectile dysfunction due to arterial insufficiency
• N52.31 Erectile dysfunction following radical prostatectomy
• N52.32 Erectile dysfunction following radical cystectomy
• N52.35 Erectile dysfunction following radiation therapy

CPT codes are treatment codes that tell the insurance company what procedure we have performed.

• 54400 Insertion of a penile prosthesis; non-inflatable (semi-rigid)
• 54401 Insertion of a penile prosthesis; inflatable (self-contained)
• 54405 Insertion of a multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir

Next Steps

If you believe that a penile implant may be the appropriate option or are on the fence and want to speak to a men’s health specialist like Dr. Natale, we encourage you to schedule an appointment with our office. We hope you develop a comprehensive list of questions Dr. Natale can answer thoroughly. We look forward to helping you in the near future.