Denied coverage for an implant?

You may be able to appeal the decision. Find out how.

You have been denied coverage.

If you find out that your insurance company has denied authorization for payment of the procedure, the first thing you need to do is determine the type of denial. Is the denial based on a contract exclusion?

Review your benefit information for specific exclusion language. Some types of contract exclusions include no payment for:

• Sexual dysfunction
• Impotence
• Sexual inadequacy
• Penile prosthesis
• Penile implants

Review your benefit information for specific medical benefits such as:

• Prosthetic devices
• Reconstructive surgery
• Surgery to repair body function

You have the right to appeal any denial from your health plan. In many cases, there is a time limit following the denial in which your appeal must be received. Check your benefit information or any denial letter you received for specific timelines.

You’ve appealed, but insurance still won't pay.

If the contract language has a clearly written exclusion, your insurance may legally continue to deny coverage. What are your remaining options?

Review other medical policies you may have.

• Do you have Medicare?
• Are you covered under a secondary plan by someone else, such as a spouse?
• Have you served in the military and are you covered under TriCare?
• Do you qualify under Cobra to be part of another plan?

Is your health plan a self-funded program? Check with your human resource department to determine whether you are covered under a self-funded program. Employers can make a final determination for coverage in self-funded plans. Request information on the process involved in having your request reviewed for coverage.

Explore the opportunity for open enrollment.

• This usually occurs at year-end and may allow you to choose another health plan
• Determine whether another option is offered that may have benefits for erectile dysfunction and penile prostheses
• Determine whether you are able to upgrade your current plan by paying extra premiums (these are referred to as riders)

Consider self-payment.

Paying for your surgery out-of-pocket may not be the most desirable option. It may be your only option if you have exhausted all other options. Here are considerations that could make self-payment more feasible:

• Negotiate prices
• Explore all of your options regarding where you can have your procedure performed. If your health plan is not paying for any of the costs, then you are not obligated to follow any rules set by the health plan. You would not be limited to facilities in network. You may research prices at different facilities and negotiate a price you are the most comfortable with
• Utilize pretax flex spending plans
• Explore loan options

Call for assistance with exploring your options at 1-888-865-3373.