Chance my health insurance will approve an implant?

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Dared

So as some of you know, i am scheduled for implant surgery in a few weeks. I am wondering if there's any chance my health insurance will even approve this operation. First of all im 25 so they may try to use that to say i dont neee it. Other then that ive just noticed a pattern of insurance not approving treatments for the penis but especially erectile dysfunction. I have united healthcare choice by the way and its pretty good coverage because i only have a 500$ deductible.. I dont know i'd like to hear some opinions/experiences.  

TonySa

Be sure to seek approval before you have the surgery or they will undoubtedly deny paying for it.  Your doctor should be able to request authorization in advance.
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.

JohnWright

Insurers are going to provide coverage for medical procedures ordered by a doctor.

The actual question is: IS the surgeon you've selected an approved provider for your particular insurance company??? I had to go shopping in order to find a surgeon who as approved to work with my insurer before I even wasted my time interviewing the surgeon to determine if he was worthy of touching my junk.

The doctor (or your insurer's provider list) can tell you if your surgeon is an approved provider. Prior to surgery my surgeon was able to give me an advance quote of what the cost to me would be after insurance deductible.

Dared

Johnw: that is good to hear as i know that the surgeon is contracting with my insurance. That was the first thing I asked the nurse on the phone before proceeding with the surgery. As far as whether or not Kramer is a good surgeon. I consted FT forums in regards to that and the guys over there unanimously agree he is in the top three best surgeon in the entire country for implants. Now, whether or not he is a top surgeon for implant with peyronies disease i am unsure. Perhaps peyronies disease adds complications he may not be as familiar with? All i know is he has an exquisite reputation for implant procedures and hes a high volume implant surgeon as he performs five to ten of these procedures per week. So im fairly confident but not completely.  

TonySa

John, you must have a great PPO insurance, if it's an HMO insurance or not a great PPO plan you need PRIOR AUTHORIAZATION for treatment.  Don't get stuck with tens of thousands $ bill if you can prevent it—seek authorization in advance.  And, yes seek priorbauthorization with the best MD on your panel.
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.

JohnWright

Dared -- While it's good that there are implant forums, you'd be without excuse if you didn't visit Kramer's YouTube channel. I've been promoting it here for over a year. If you watch each of his videos at least once, you'll make up your mind with absolute certainty.

Watch his videos -- https://www.youtube.com/channel/UCdkQplDRDJF-vudzD1g9JGQ/videos

John


TonySa

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.

Stabler

Dared,

Your surgeon will/should be checking to see if the surgery will need an authorization/approval from your insurance however it is in your interest to check this out with your insurance company yourself. You will want to make sure that the surgeon, anesthesia and facility where you will be having this done are IN NETWORK with your insurance plan. It is in your best interest to call your insurance company (member services on the back of your card) and have the NPI (National Provider Identifier) or Tax ID for each surgeon,location,anesthesia so they can look them up effectively.

You also want to make sure they are going to be using appropriate diagnosis codes- Peyronies disease (N48.9) and not just ED (N52.9) Just using the code for ED can make it a "Cosmetic" type of procedure on your plan Peyronies makes it "Medical" again your surgeon should know this but you need to be the one to confirm

You want to ask what your coverage is for Peyronies disease on your plan. They can tell you what you will be responsible for financially if given the correct codes. You should call the surgeon and ask them what CPT code (code for surgery) they will be using for the surgery itself. This code tells the insurance company what they will be billing for.

The surgeons office is only going to be checking these things for THEM not the location where you will be having the surgery. You must do your part, You have to be the one to make sure this is covered do not leave that up to the surgeon. He is looking out for him. You have to know your benefits, be your own advocate.

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.

TonySa

Thanks for giving him all the details Stabler...your message should be sticky so everyone can  make sure insurance covers any procedures 💓
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.

Dared

I know the surgeon is in network the rest of it not sure.  

TonySa

That's great news.  I'd next call the insurance on your card and ask if the surgery has been approved as it's inntwo weeks.  Hopefully, your doc handled the approval process for you.  
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.

JamesM

I also have United Healthcare. Prior to my implant surgery (2 weeks ago) I had already reached my out of pocket deductible for the year from a knee arthroscopic. My surgeons office worked out all of the coverage with UHC. My complete total out of pocket was 2,500 for the implant surgery.