Insurance Woes

[TheTexican]

Not sure what help y'all can be, so this may just be a vent to make me feel better.

I'm scheduled for plication surgery in a couple of weeks but my insurance is balking, stating that they don't cover sexual dysfunction issues. My surgeon is trying to use different rationale, since I at a 90 degree+ upwards bend and he's sure this Peyronies is the result of my prostatectomy.

The insurance folks need additional info, so there's still a chance. Hopefully my doc knows how to maneuver in these waters.

Thanks for all the support, fellas.

TheTexican

[Stabler]

Hello Texican,

Your doctor needs to make sure that the insurance is not looking at this as a sexual dysfunction surgery but a medical surgery due to Peyronies disease, if your insurance is thinking this is simply a cosmetic surgery they will do all they can to not have to cover it. Your doctors office should know what needs to be said and sent to them to get this approved, they should have a person that handles the authorizations in the office that knows what is needed. You can call your plan and ask them what information they are still needing from the doctors office so that it will be approved and then make sure that the office knows what your plan is waiting on from them. Be diligent, call the insurance very day to check the status. Make sure they have the diagnosis code of N48.6 for Peyronies disease this makes it medical and not cosmetic or something you just want done so you can have sex.

Stabler

[TheTexican]

Thanks, Stabler. Great information.  

[Stabler]

No problem its what I do for a living

Stabler

[TheTexican]

I got the pre-certification from the insurance company today. Nov 16 will be here soon. Thanks again, Stabler.

TheTexican

[Stabler]

That is great news... Keep us updated on your progress!!

Stabler

[TheTexican]

Well, bad news. The insurance company made a mistake and misinformed me. I've been denied because my company doesn't cover any surgery related to sexual dysfunction, even though my surgeon deemed it medically necessary. They refuse to budge. I can appeal, but only retroactive to the surgery. I certainly can't afford to pay for this on my own but living with this 90 degree upward curve is not easy.  

[Stabler]

Have your doctors office do the appeal and reschedule the surgery. It is always a fight with insurance. Have them do the appeal.

Stabler

[TheTexican]

Thanks, Stabler.

The doc's office said they'll file an appeal but the language would be pretty much the same. The issue is my employer's exclusions, which are quite prudish.

I have an opportunity to change insurance in January. I may do that and start over.

It's been a long, discouraging afternoon.

[Alibaba]

Not a sexual dysfunction issue.  Primary diagnosis was prostate cancer. Secondary diagnosis was peronies subject to reduced blood flow from the prostatectomy.  If there is any pain involved, then the peronies pain all secondary to the prostate cancer.  Explain it in those terms and make sure the doctor codes it that way. Explain it in those terms to the rep from AMS and have her do a conference call with the insurance company and you. The AMS reps are more helpful than Coloplast and DO know what the codes to use are to get the job done. The new ICD10 codes have many more categories to define your issue.  If you have had a prostatectomy, you are NOT doing this to promote conception, an often used denial. A vasectomy is part of the prostatectomy, it is just done in your abdomen instead of your sack. Do not give up. Cheers man. Been there.    

[TheTexican]

My surgery is still scheduled for this Friday. The insurance company is giving my doc one more opportunity to submit materials. I'm using what y'all have suggested here in my conversation with the doc.

What a tremendous forum this is. I'll keep you posted.

TheTexican

[TonySa]

I'd postpone the surgery until the insurance approves it, or denies it and then try to negotiate a cash discounted price.

[Alibaba]

I'll keep you posted.

TheTexican

Please do. Hopefully with the minds of many someone will come up with an answer to bring the insurance company to their knees so they can see your penis eye to eye!

[TheTexican]

Met with Doc today. No go for surgery this week. I'm switching insurance January 1, so we'll wait until after then. After I got home, my surgeon called and said we may want to explore an implant since I'll have new insurance.

Thanks again, friends.

TheTexican