Permision from Xiaflex

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chasema

Approx two weeks out from when I thought hospital was getting approval from insurance company, decided to call Highmark for update on when they will give the ok. Turns out they knew nothing about it. Hihgmark insurance took it upon themselves to call the hospital since I can never get anything but answering machines and a call back at what turns out to be the worst times for me to get calls and end up missing them. The doctors office called me back within minutes after Highmark called. (Thank You Highmark). The person that is tasked with sending paperwork out from doctor said that they need to first get the makers of Xiaflex approval witch I personally don't understand why. Apparently said paperwork not sent out and they are processing it at this time, (After getting call from insurance company). FINALLY. It takes long enough to get these shots without doctors sending in paperwork in a timely manner. If I didn't have to start over again I would consider going to another hospital altogether. The doctor from this hospital couldn't even feel the plaque that a doctor from competitive hospital had no problems feeling it. I hope her report of plaque not being palpable  doesn't kill my chances of getting these shots. Not happy at all with the way this hospital handling this. Basically I just wanted to vent here and get this out of my system because this just irritates the hell out of me when a person cant get decent service anymore. Or maybe I'm out of line here.

Stabler

It does not make sense that they would need permission from XIAFLEX to give you the medication. The "approval" part of this is from your insurance company. I have worked with Highmark in the past in my medical field and they are pretty easy to get approvals for specialty medications. Are you sure you understood the doctors office correctly? I'm not doubting you, it just doesn't make sense as I do this for a living getting approvals for medication.

Keep us updated
Stabler67  
Moderator since 2015- Missouri- I work in the medical field and have strong knowledge of insurance and how to obtain coverage for medication and other treatments. Being a woman I do not have Peyronies but you can ask me anything. I am happy to help.

betterbend

Endo has a reimbursement specialist, so possibly they were assisting with some of the criteria for approvals.  I get your frustration with the approval paperwork and the hospital dropping the ball.  Unfortunately doctors offices are bombarded with prior authorization requests from insurance companies.  Some of these are understandable insurance company requests, but some are ridiculous.  Nobody gets paid for all this extra work.  Its completely gummed up the system and the best way to see that something like this get done is to be on top of it yourself.  Stinks, but its the only way...  
55 - Onset May 2017.  38 degree bend up.  Failed Xiaflex treatment.  Still functional so I decided to stop treatments.  Only take 400mg Co-Q10 and occasionally use Restorex

TonySa

Chasema, you have it correct...both insurance and xiaflex approval is needed.  I'm not sure why xiaflex auth is required...perhaps to keep liability issues down?  Their process is usually same week (I went through it twice since I decided to go w a high volume specialist).  Just make sure your provider does a lot of xiaflex injections regularly as the docs proper precise administration is key to success.
PxD 2 yrs 9/16.  Failed all treatment. 9/11/18: excision, grafting & implant Dr Karpman MtnView Ca, AMS CX 18cm + 3-1cm RTEs.
Pump failed.  2/11/20 Dr Karpman installed Titan 22cm +1cm RTE.

chasema

Thanks for all the input. I can understand if it pertains to liability. You  mentioned a doctor with high volume, the doctor doing injections is listed on Xiaflex website as a specialist that has done 20 or more shots within last 12 months. Glad its not my urologist that can't even properly diagnose it Also curious to know if anyone had the procedure that has been explained to me as follows. I was told it will be done in operating room at the urologist office where they will put me out and put a needle in the end of my penis to induce erection with a syringe make area of bend draw out whatever they used for erection then administer the Xiaflex magical potion. I have never heard this done in this fashion, have any of you? According to my urologist they do it this way because guys don't like needles in their penis. That makes sense.  Also would be quicker since the need to wait for erection and then for it to go down, A real time saver in my opinion. And the fact I'd rather be unaware of what is happening to Mr. Happy. Only problem is getting put out I will need a ride there and back and can't return to work.

TonySa

I've never heard of being put out for these injections.  That would add in the possible complications of anasethesia.  Maybe they mean a mild sedation?  What doc is this?  Maybe do a search on this website or ask others if they've had this doc.  I'd still ask how many injections they've done, 20 is not really many at all.
PxD 2 yrs 9/16.  Failed all treatment. 9/11/18: excision, grafting & implant Dr Karpman MtnView Ca, AMS CX 18cm + 3-1cm RTEs.
Pump failed.  2/11/20 Dr Karpman installed Titan 22cm +1cm RTE.

chasema

Yes your probably right about being under conscious sedation as opposed to general anesthetics Tsanchez, but I remember her saying put out, let you know when the time comes. As for the doctor doing shots his name is  Michael Evankovich  from St. Vincent hosp Erie pa. Anyone know of or has been under his care. According to Xiaflex he has done 20 or more shots within 12 months. Also even under conscious sedation a person could still feel the pain from shots but won't have memory of it from what I understand.

betterbend

Maybe there is a medical reason for sedation, perhaps your plaque is in a very sensitive area that will be a particularly painful injection, but if its not, there really is no reason for sedation or anesthesia.  The injections, while annoying, and maybe slightly painful, think bee sting, there really isnt a lot of pain.  I would say unless you really think you need it, try it without the first time.  If its bad, then try a local anesthetic.  I had four injections, and I only found one to be painful, and it really wasnt that bad ...
55 - Onset May 2017.  38 degree bend up.  Failed Xiaflex treatment.  Still functional so I decided to stop treatments.  Only take 400mg Co-Q10 and occasionally use Restorex

TonySa

Dr Lue does do a local anaesthetic.
PxD 2 yrs 9/16.  Failed all treatment. 9/11/18: excision, grafting & implant Dr Karpman MtnView Ca, AMS CX 18cm + 3-1cm RTEs.
Pump failed.  2/11/20 Dr Karpman installed Titan 22cm +1cm RTE.

chasema

Betterbend I believe the reason for sedation is because the gauge of butterfly needle used for artificial erection is larger than a needle for shots and the placement is through the tip of the penis into the erectile bodies. This procedure is used for when surgery is taking place and an erection is necessary. An explanation of this is as follows. "An artificial erection is usually achieved by puncturing the corpora with a 21G butterfly needle and inflating the penis with normal saline".  It is my opinion when done in this way they cut down the time doctors need to spend with the patient and not having to wait for an erection or waiting for it to become flaccid again. This makes perfect sense and I would be all for this if it helps the doctor with better Xiaflex needle placement and simply not remembering or feeling anything.

I should also add that why this is done is pure speculation on my behalf, not necessarily the correct reason.  

betterbend

Did you already get an ultrasound?  
55 - Onset May 2017.  38 degree bend up.  Failed Xiaflex treatment.  Still functional so I decided to stop treatments.  Only take 400mg Co-Q10 and occasionally use Restorex

chasema

No ultrasound yet. I would think this would have been done by now since the urologist claimed she couldn't feel it. As mentioned above a doctor from another hospital had no problems palpating it. I am almost sure my claim will be turned down this first time she doesn't know what she is doing. Anyone ever call the Xiaflex makers to plead their case with them. If anyone has the number please post it.

TonySa

I think they just want to see a 30 degree curve existing for a few months.
PxD 2 yrs 9/16.  Failed all treatment. 9/11/18: excision, grafting & implant Dr Karpman MtnView Ca, AMS CX 18cm + 3-1cm RTEs.
Pump failed.  2/11/20 Dr Karpman installed Titan 22cm +1cm RTE.

chasema

If that is the only criteria then it shouldn't be a problem. Time will tell.

betterbend

Here it is from the Endo website.  But its not them you have to plead with.  They are there to assist you.  It is your own insurance plan that will approve or deny, usually based on their criteria and your policy.  My plan had to see doctors notes indicating a >30 degree curve for greater than six months and a palpable plaque.  Once they had that from the doctor they approved.  The Xiaflex line will assist your doctors office in generating a letter of medical necessity.  Dont forget there is a coupon from Endo also that will cover up to $1200 per injection of uncovered costs.  My insurance covered the whole thing except $200, which got paid for by Endo.


XIAFLEX® is covered by Medicare and for ~93% of claims for patients with commercial insurance*
Patient benefit design may vary, please be sure to verify your patients' coverage via the XIAFLEX® Reimbursement Helpline at 877-XIAFLEX (877-942-3539)
55 - Onset May 2017.  38 degree bend up.  Failed Xiaflex treatment.  Still functional so I decided to stop treatments.  Only take 400mg Co-Q10 and occasionally use Restorex

chasema

Great information betterbend. I will call them tomorrow.

chasema

Why waste time. I just called Xiaflex they say you need to have palpable plaque. That my urologist could not feel but was easily felt by another doctor. My bitch at this time is if hospital personnel know this is part of that criteria why even turn in paperwork if they know it will be denied, and at the very least get a doctor that knows what they are feeling for so they can send proper information into Xiaflex and insurance.  This is really getting exasperating for me. I've had this condition for 15 years and lived with it since there was only surgery, finding out I have an alternative was great with Xiaflex. And this doctors incompetence is ruining my chances or making it take longer that it should have. Tomorrow I plan to call her office and drop her for someone that knows what they are doing.

Junior

I am confused I went to the doctor in October 2018. He told me to take vitamin E to take a picture of my penis looking down at it & one from the side and also to take pictures 4 months from now.

He setup an appointment to come in for an ultrasound & office visit  in Feb 2019. I think my degree of ........... is about 35 degrees. I noticed my  curve penis in July 2018, I might of noticed lost of length earlier. The reason I went to the doctor was because I saw ads on TV for xiaflex for .......... & realized that I may have it.

He told me of the different treatments and said the one that he recommends is Xiaflex. He said it is expensive & that Medicare does not cover the Xiaflex.
I called Endo & they said it is covered by Medicare, Part B & not Medicare Part D (prescription). I called Medicare (D) they said they cover injectable drugs, I didn't go into Xiaflex at that time talking to a woman & to embarrassed. I also have Dupuytrens's Contracture in my left hand for a few years now & I thought I had it in my right hand at first & it went away.

Has anyone on Medicare & a Medicare supplement been through the Xiaflex treatment that had success & was approved by Medicare & their Medicare supplement?


Thanks

John


ED - born 1952   /Peyronies Disease Onset 7/2018 at 65 / Prostatectomy 4/1/2019 / Low - T testosterone therapy June 2019 / June 2019 Peyronies Disease at 70 degrees - July 2019 started Xiaflex 1st cycle

Stabler

Hi John,

Welcome to our forum. What Medicare supplement do you have and is it the plan that your prescriptions are covered under?

Stabler
Moderator since 2015- Missouri- I work in the medical field and have strong knowledge of insurance and how to obtain coverage for medication and other treatments. Being a woman I do not have Peyronies but you can ask me anything. I am happy to help.

Junior

Hey  Stabler,

Thanks for your email, I have Medicare B Supplement(  Aetna Plan G) & my prescriptions are covered under my Medicare D Plan is separate & also Aetna. It's my understanding from Endo that Medicare Plan B should pay for Xiaflex.

John
ED - born 1952   /Peyronies Disease Onset 7/2018 at 65 / Prostatectomy 4/1/2019 / Low - T testosterone therapy June 2019 / June 2019 Peyronies Disease at 70 degrees - July 2019 started Xiaflex 1st cycle

Stabler

Hi John,

Yes, Ideally, Medicare B should pay since it is being done in the Dr's office. The Med will go to them and they will be administer it. It's not like you are going to your local pharmacy for this. It should not have to go through your Part D plan or need an authorization.

Stabler
Moderator since 2015- Missouri- I work in the medical field and have strong knowledge of insurance and how to obtain coverage for medication and other treatments. Being a woman I do not have Peyronies but you can ask me anything. I am happy to help.

betterbend

Your doctors office should be doing a pre-authorization for the procedure to check on the coverage and copay.  THis should all happen now prior to any treatment.  But make sure you fully understand who is billing.  In my case there was a hospital bill and then a separate outpatient doctors bill.  The drug was paid under the hospital bill for 7500, the doctor billed a separate $500 fee for his injection, and billed seperately for the ultrasounds and measurements, that went to a different insurance company.  Talk to your insurance company and the doctors billers once they do the preauthorization.  Get a total picture of your costs...
55 - Onset May 2017.  38 degree bend up.  Failed Xiaflex treatment.  Still functional so I decided to stop treatments.  Only take 400mg Co-Q10 and occasionally use Restorex

Junior

Stabler,

Were you on Medicare at the time  & did you have a Medicare Supplement.

Thanks


John
ED - born 1952   /Peyronies Disease Onset 7/2018 at 65 / Prostatectomy 4/1/2019 / Low - T testosterone therapy June 2019 / June 2019 Peyronies Disease at 70 degrees - July 2019 started Xiaflex 1st cycle

Stabler

Hi John,

I work in insurance and take care of authorizations for medication and testing (not Xiaflex but the process is the same) that's where my knowledge comes from. Also in case you didn't notice, I'm a woman, so I don't have Peyronies. I just try to help out in the forum as much as I can.  ;D

Stabler
Moderator since 2015- Missouri- I work in the medical field and have strong knowledge of insurance and how to obtain coverage for medication and other treatments. Being a woman I do not have Peyronies but you can ask me anything. I am happy to help.