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Author Topic: How to make insurance companies to cover medications, VED, surgery for Peyronies  (Read 6737 times)

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Stabler

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Okay

Because Mamma loves you all so much and because Mamma has pretty big Kahunnas herself...... this is what I have been doing today. (yes while I am at my job I am working to help you boys)

I called Dr Stephen Brandes office (he is one of the urologists on our list) and asked to speak with the person in charge of their precert/approval department for the Peyroines medications, VEDs etc...
Now like I said approvals for medication is what Mamma does for a living but I dont do it for Peyronies, so I went directly to the source. (a perk working in a Dr office)

Here is what I am told:

Coverage for all meds for Peyronies is difficult (you all know this) the reason in many cases is the way that your plans are structured. You need to know what kind of coverage that you have. This means work on your part. Call your insurance company (Member services # on back of the card)  and ask them what your coverage is for Peyroines. Have the names and doses of the medications and have the diagnosis code for the type of Peyronies that you have. Ask what your coverage is for penile surgery as well for the diagnosis of Peyronies to make sure that you have coverage for this.

If you dont know this code call your doctors office and get it, there are several different codes depending on the type/variation of Peyronies. The general diagnosis code is 607.85 but if you have a variation of the disease this code may be different.

Also ask them about coverage for VED machines. I was told that Medicare will not cover them at all and Blue Cross Blue Shield and United HealthCare are very hard to get a VED approved through, other insurance companies not so much a problem.

Here is the most important part.
When your doctors office goes to get the medications approved for you, they MUST use a diagnosis that you HAVE. they cant fabricate something in order to try and get you the medication. First and foremost that would be fraud on their part and second that would be giving you a health condition that you dont have, should you ever change insurance for some reason, you dont want to have any reason for them to deny a claim or deny you insurance. So make sure your doctors office are using proper protocol when getting your medications approved.

Dr Brandes office uses proper protocol and they will fight like mad to get the meds/VED/surgery approved appealing if needed and everything, make sure your doctors office follows these same guidlines for you.

Now, I was given a direct number to the person I spoke with, so if we have more questions or if there is something I did not cover that you all want to know on this subject, ask me and I can call and get us the answers.

Okay boys,  Mamma has to get back to work!!
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james1947

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Hi Stabler

Thanks for your effort and the input.
I am changing the topic title to:
"How to make insurance companies to cover medications, VED, surgery for Peyronies"
As it is not clear what the topic is about with the old name, "Please Read- This could help"
Maybe the topic should go to:
Open Questions or General Comments (that won't fit under any other topics) - PDS - Peyronies Society Forums

James
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Age 71, Peyronies from Jan 2009 following penis fracture during sex. Severe erectile dysfunction.
Lost 2" length and a lot of girth. Late start, still VED, Cialis & Pentox helped. Prostate surgery 2014.
Got amazing support on the forum

Stabler

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James please put it where it will best be seen. We now have a good first hand resource for our questions. I think we should utilize it.
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james1947

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I am setting the topic sticky

James
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Age 71, Peyronies from Jan 2009 following penis fracture during sex. Severe erectile dysfunction.
Lost 2" length and a lot of girth. Late start, still VED, Cialis & Pentox helped. Prostate surgery 2014.
Got amazing support on the forum

wonderbread1662

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Starting to sound like a broken record here but thanks again for this Stabler. I will bookmark this to make sure my specialist and I are on the right page to get me covered for as much as possible.
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pey ron

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so, this thread has been dead in the water? there's really no way?
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TonySa

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That’s just her motto ☹️
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pey ron

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@Stabler67: do you know if I can buy the restorex and the augusta medical VED with my HSA debit card? Do I need a writter prescription by an urologist in case the IRS later audits me?

thank you!
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betterbend

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I spoke to my FSA provider today (wage works).  I asked about a traction device, i told the rep for Peyronies he had no clue.  HE told me to download the letter of medical necessity from their website and have the doctors office fill it out.  The nurse practitioner can do it, it's pretty short.  With that he said they will pay it out of the account.  I will check back if i go ahead and buy it.
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Stabler

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@ Pet ron,  It will depend on the structure of your HSA plan. on mine I am unable to use it to purchase over the counter items Like aspirin, vitamins etc... but medical supplies for my diabetes are covered like meters, test strips etc... your HSA plan should have a guide for you or a number you can call to see what type/class of items can be covered by the plan, and yes a script for it is usually necessary to show proof that a dr is ordering it for you.

@ Betterbend,
Yes use the letter that is available and let the doctors office fill it out. They should know what information to send to help support the coverage of the traction device.

@ForestLover, yes Mamma is just a motto I use.

Stabler67
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pey ron

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@Stabler67, thank you :)

I wonder if I made a mistake and should have tried to have the H-100 billed to my insurance before paying 100% of it with my HSA debit card, so that it would have counted towards my max-out-of-pocket for the year even if they didn't cover it.

Do you know?

thank you, thank you! It's so difficult to navigate the system!
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Stabler

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Pey Ron

It would depend if your plan would have coverage for the device. If you call your plan benefits they would or should be able to tell you if you have coverage for that. If they do and you can get reimbursed from your HSA  then I would try that but you will want to make sure you plan will cover it. Your Drs office may be able to help you with this as well.

Stabler67
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pey ron

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@Stabler67: it's a topical cream, not a device... I've bought it through my HSA debit card. But I haven't had it billed to my insurance, which instead would have helped me reach my max-out-of-pocket.

Is there a way I can go back to my insurance and report this expense?
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Stabler

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My mistake, I apologize.

My advice would be the same though, to check and see if it is covered by insurance. I don't know if they will reimburse you but it never hurts to ask. If they do cover it under your insurance some plans have reconsideration forms that you can file to get paid back for a medication you have paid out of pocket for. Call your plan and ask.

Stabler67
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pey ron

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@stabler: if I go to a specialist abroad, outside of the US, can I use my FSA funds for their services *AND* for the flight ticket?

I need to figure out by tomorrow how much to contribute to the use-it-or-lose-it FSA for next year...

thank you!
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Stabler

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An FSA plan is money you contribute but usually only applies to certain things or items (depending on who the administrator of the plan is. I have an FSA acct that is handled by a company called Beneflex it covers most of my diabetic supplies and I could use it for for some prescriptions, Dr visits and such but not if I traveled out of the country. It would be best of you contact the group that handles the plan and ask them if the benefits can be used if you are out of the country.

Stabler
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Perceptible Curve

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I am currently in the market for a VED and my doctor has granted a prescription for it, however it falls on me to see if it is approved and covered by my insurance. The CPT Code is L7900 in case anyone needs to know. When that call is made I will be sure to post the results here for informational purposes within the forum.
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Stabler

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Yes please let us know and thank you for supplying us with this CPT code
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Alibaba

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Doctor Brandes was my doctor at the time I was prescribed a vacuum pump. His office could not get it approved. The reason was they were using the code for erectile disfunction instead of the code for post surgical prostate cancer as the primary code.  2/3rds of the policies now have an exclusion for anything "that promotes conception".   If you have peronies pain, had prostate cancer, have had a prostatectomy, had a vasectomy, have had an injury, have had abdominal surgeries, those need to be your primary code and whatever as secondary.  Prostatectomy and vasectomy already negate the "promotes conception" BS.  Codes are deeply defined now. The new ICDN10 codes have about 3 times the codes and sub catergories of old codes.
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Perceptible Curve

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Sorry I took so long, finally called the insurance company to get approval of VED. Using the CPT code L7900 they said it is covered. They also asked for a diagnostic code that I did not have on hand but apparently wasn't necessary in my case. Will call my doctors office tomorrow and get it ordered. One thing that boggles my mind is the fact that medical grade VED's are so expensive, around 5 or 6 hundred dollars "unbelievable". Put the word medical in front of anything and it triples in price.

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Alibaba

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Agree with you about price.  The L7900 code is Male vacuum erection system .  Most of the time to get that "treatment" covered you have to have the proper medical diagnosis code why that treatment is needed.
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