Insurance coverage for erectile dysfunction treatment varies. If you have insurance, it is important to understand coverage options associated with penile implant surgery. Need help?
Regardless of your insurer, it is important to confirm your benefits. If you have an insurance plan that covers penile implant surgery, your doctor will work with you to address requirements that must be met prior to a procedure. If your insurance plan does not cover penile implants or if you have a benefit exclusion, you will be responsible for all charges related to the surgery.
Medicare or a Medicare Advantage Plan will typically cover a penile implant procedure if it is deemed medically necessary. Your doctor is very familiar with their responsibility to document your treatment journey in your medical record. This record will aid in showing that a penile implant is medically necessary. It is proof that you need the device to achieve an erection.
The amount you will pay out-of-pocket will vary by plan (e.g., Medicare or Medicare Advantage) and the type of facility where the penile implant procedure is performed. Surgery for a penile implant can be done at a hospital on an outpatient basis or in an ambulatory surgery center.
All penile implants manufactured by Boston Scientific (the AMS 700TM series implant, AmbicorTM implant and TactraTM implant) are devices to treat ED; they may all be eligible for coverage under Medicare and Medicare Advantage when deemed medically necessary. Talk to your ED specialist’s office about eligibility.
Insurance plans through your employer or health insurance that you’ve purchased yourself are often referred to as “commercial” plans. If a commercial insurance plan covers penile implant surgery, they will often have specific requirements that must be met. Others will determine coverage based on medical necessity. Some may exclude benefits for a penile implant altogether.
If penile implant surgery is covered by your insurance, your doctor will likely have confirmed your benefits and obtained any necessary authorization from your insurance. However, this is not a guarantee of payment. You should contact your insurance plan directly to confirm your insurance benefits include coverage for a penile implant. The contact information for your insurance plan is typically on the back of your insurance card. All penile implants manufactured by Boston Scientific (AMS 700TM series penile implant, AmbicorTM penile implant and TactraTM penile implant) are devices to treat ED and qualify as reimbursable when an insurance plan covers penile implant surgery and you qualify for the benefit.
Keep in mind that how much you will pay out-of-pocket will vary. The cost you pay for a penile implant will differ depending upon your insurance plan and the type of facility where the procedure is done. Your co-pay, deductible and co-insurance will determine your financial responsibility (the amount you will have to pay).
If penile implant surgery is not covered by your insurance, you will first need to determine the reason for non-coverage. Your insurance may have determined a penile implant was not medically necessary and therefore will not allow coverage. This is often called a “denial.” Or, the plan you have may not have benefit coverage for ED treatment and/or a penile implant. This is often referred to as a “benefit exclusion.”
Individually purchased health insurance is also often called a “commercial” plan. It is like an employer-sponsored health plan. Read the section entitled “My insurance is through my employer” for an overview of how to proceed when your benefits cover penile prosthesis (penile implants) for treating ED. The above section also tells you what to do when the insurance plan you have says you have non-coverage, or when benefits exclude coverage for erectile dysfunction treatment and/or penile implants.
State Medicaid and Medicaid Managed Care coverage may vary by state and by plan type. You should ALWAYS confirm your benefits before an implant procedure. If the penile implant is not covered by your state Medicaid or Medicaid Managed Care, you will be responsible for all charges related to the surgery.
All penile implants from Boston Scientific (the AMS 700TM LGX, CX or CXR Penile Implant, AmbicorTM Penile Implant and TactraTM Penile Implant) qualify as devices that offer treatment of ED where medically necessary. Medicaid plans that cover ED treatment will typically need for the implant procedure to be authorized. Your doctor’s office can help with this. Again, you will want to confirm your coverage details prior to the surgery.
When the insurance plan you have says that there is non-coverage for a penile implant or that you have a benefit exclusion for this ED treatment option, don’t stop. Even though the plan you have may not have benefit coverage for a penile prosthesis, you can ask for a benefit exception. See the tip above. Start by getting a copy of your Summary Benefit Plan (SBP) or Summary Plan Description (SPD). Then, work with your ED Specialist’s office for help. Or, contact a Boston Scientific Patient Procedure Access Specialist at (855) 284-1676, option #1 for assistance. Another option to consider is changing your insurance plan during open enrollment. If you make a change to your insurance, you will want to confirm the insurance plan you are evaluating covers ED treatment and a penile prosthesis/implant.
If you do not have health insurance right now and are ready to proceed with your penile implant procedure, visit the Cash Pay page for information on your options. Negotiated fee and financing options are often available. For example, you can let your doctor know that you will be paying for the surgery yourself. Ask your doctor if a financial assistance program is available. Alternatively, some clinics offer cash-pay discounts or a price break for timely or early payment. Lastly Boston Scientific, the market-leading penile implant manufacturer, offers a financial assistance program for eligible patients. If you are considering purchasing insurance in the future, you will want to research your plan options and learn which plans cover ED treatment, including penile implants.
The Mission Act replaced the Veteran’s Choice Program back in 2018. This change allows veterans to receive medical care from physicians within the public sector. In order to receive medical care from a private physician, you first need to make an appointment with your VA physician to determine eligibility. It is important that the VA confirms eligibility before making an appointment with a community physician (outside the VA) in order to make this referral. Community physician charges should be similar to those from a VA physician.
For non-VA care, in order to determine eligibility for a penile implant procedure, it is important to have the procedure prior-authorized.
For patients with Veterans Administrative Benefits (CHAMPVA), the process is different from Non-VA care. Pre-authorization for VA’s should be handled by the Veteran and the Veteran’s Administration. The Veteran needs to obtain a referral and an authorization for care which is generated by the local Non-VA Medical Care office. This is typically sent to the Veteran and to the provider. You should have a copy of this prior to receipt of care
Navigating health insurance coverage can be complicated. Boston Scientific, the sponsor of EDCure.org, has Patient Procedure Access Specialists to help you understand insurance coverage for penile implants as well as general information about anticipated out-of-pocket costs.
Call Boston Scientific’s Patient Procedure Access Specialists at (855) 284-1676 option #1. They’re available to discuss options. Or click HERE to get the navigating insurance worksheet to help get the insurance information you need.
Although requirements for insurance coverage for penile implants will vary from plan to plan, when your plan has coverage for penile surgery, they will typically have common steps. You will go through the process to get your procedure approved. The good news is that the required medical documentation men will need is often built when men go through a treatment journey to find a solution to their ED. Required information may include:
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Caution: U.S. Federal law restricts this device to sale by or on the order of a physician.
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How much a penile implant costs depends upon several factors. If you have health insurance that covers ED treatment with a penile implant, your financial responsibilities will be reflected in your co-pay, deductible and co-insurance.
Getting a penile implant can cost anywhere from just a nominal co-pay to over $25,000. Where the implant procedure is done may affect the cost. The type and extent of insurance coverage and your current deductible situation are factors in how much you will pay out-of-pocket for a penile implant procedure. For those with insurance coverage, out-of-pocket fees can range from a few hundred dollars to a few thousand dollars. If your health insurance does not cover ED treatment with a penile implant or if you do not have insurance talk to your doctor. Some physicians offer flat fee or discount packages. Package options include the cost of the penile implant and associated surgery fees. Prices can range from $17,300 to $26,700.77
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CPT Code Current Procedural Terminology (CPT®) codes are part of the system used by doctors to describe the procedure performed or the services provided. They use CPT codes when submitting claims to health insurance plans.
Co-Insurance A percentage of the cost of covered services that a patient is responsible for after they have reached their deductible. This is a form of cost sharing between the insurance plan and the patient. For example, after the patient’s deductible has been met, the insurance plan will pay 80% of charges for covered services and the patient is responsible for the remaining 20%.
Co-Pay A fixed out-of-pocket amount paid by the patient when he receives services.
Deductible A fixed out-of-pocket dollar amount the patient pays for covered services before co-insurance begins.
Eligibility Describes whether the patient is active under the insurance plan and may get healthcare benefits.
In-Network/Out-of-Network In-network refers to doctors or facilities that are part of an insurance plan’s group of providers that it has a contract with. Out-of-network simply means that the doctor or facility does not have a contract with the insurance plan. In general, services obtained by in-network providers and facilities result in lower patient out-of-pocket costs.
Medicaid The health care program that assists low-income individuals in obtaining healthcare services. Medicaid is a joint program, funded primarily by the federal government and run at the state level, where coverage may vary.
Medicare The United States federal government health insurance program for individuals who are 65 years of age and older or for individuals who are disabled.
Medical Necessity Services that are reasonable, necessary and/or appropriate for the treatment of an illness, injury, or disease condition.
Medical Policy An insurance plan’s set of guidelines for determining what and when medical services, procedures, devices and drugs may be eligible for coverage.
Out-of-pocket Amount the patient pays. This typically includes the co-pay, deductible and co-insurance.
Prior-authorization (PA) / Pre-Determination (PD) A review by your insurer’s medical staff to conclude if the treatment meets their criteria for coverage. Additionally, it may decide if the treatment is a covered service and right for your healthcare needs. These terms are often used interchangeably, they are both done before you get treatment.
Summary Plan Description (SPD) / Summary Benefit Plan (SBP) A document provided to patients who have insurance. It details what benefits are included and excluded.
CPT® Copyright 2019 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.