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Author Topic: How to make insurance companies cover medications, VED, surgery for Peyronies  (Read 14926 times)

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Stabler

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Okay

Because Mamma loves you all so much this is what I have been doing today. (yes while I am at my job I am working to help you guys.

I called Dr. Stephen Brande's 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 Peyronies medications, VEDs etc...
Now like I said approvals for medication is what I do for a living but I don't 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 the back of the card)  and ask them what your coverage is for Peyronies. 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 as for the diagnosis of Peyronies to make sure that you have coverage for this.

If you don't know this code call your doctor's office and get it, there are several different codes depending on the type/variation of Peyronies. The general diagnosis code is N48.6 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 doctor's 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 don't have, should you ever change insurance for some reason, you don't want to have any reason for them to deny a claim or deny you insurance. So make sure your doctor's office is using proper protocol when getting your medications approved.

Dr. Brandes's office uses the proper protocol and they will fight like mad to get the meds/VED/surgery approved appealing if needed and everything, make sure your doctor's office follows these same guidelines 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, guys,  I have to get back to work!!
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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.

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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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

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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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.

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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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.

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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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.

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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Age: 54.
Onset of Peyronies ~16 years ago.
~45 Degree bend upwards and a bit to the left.
Completed all cycles of Xiaflex as of April 2019. Slight improvement from Xiaflex and now had a Penile Prothesis implanted Sept 9th 2019.

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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Milam 1/13/16-LGX 21cm - BAD service & surgical outcome Hated infrapubic.
Kramer revision 3/1/17 Titan 22cm + 1.5 cm extenders

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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Age: 54.
Onset of Peyronies ~16 years ago.
~45 Degree bend upwards and a bit to the left.
Completed all cycles of Xiaflex as of April 2019. Slight improvement from Xiaflex and now had a Penile Prothesis implanted Sept 9th 2019.

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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Milam 1/13/16-LGX 21cm - BAD service & surgical outcome Hated infrapubic.
Kramer revision 3/1/17 Titan 22cm + 1.5 cm extenders

Mike Colwe

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I want to buy some meds on line from River Pharmacy.ca
They want me to give them a routeing number etc.
Has anyone had any problems with this company?
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Alibaba

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Here in the states, it is common to need the prescription, doctor's signature, doctor's license number.  I am not sure what they mean by routing number unless they want the doctor's electronic prescription address so they can verify the prescription.
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Milam 1/13/16-LGX 21cm - BAD service & surgical outcome Hated infrapubic.
Kramer revision 3/1/17 Titan 22cm + 1.5 cm extenders

Stabler

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The routing number to his bank account so they can withdraw payments for the medication

Stabler
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pey ron

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so I could get the VED and the extender paid directly by my health insurance instead of with my own FSA funds?

Can I use L7900 for Peyronie's or does my doctor have to pretend I have erectile dysfunction?
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Stabler

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Pey ron

It depends on if your plan covers this kind of device. You have to call your insurance and see if it is a covered benefit. If it is, then your doctor will/should know what codes to use. In speaking with urologists offices in my area they use Peyronies disease for their patients that have Peyronies. If your doctors office has experience in getting VED covered for their patients they should know if your plan is one that will cover the device but you should always call and be sure to know what your benefits are. Always be your own advocate. The L7900 code is for the VED itself not for the diagnosis of Peyronies. When you call your insurance you can give them that code to see if it is a covered benefit under your plan. You can get the ICD-10 code for YOUR type of Peyronies from your doctor. This code is not the same for everyone with Peyronies since there are different degrees of it. You need to have this code as well when you call insurance in case they ask why you need the device.

If it is covered with your insurance ask them if there is a copay or if any of the cost will go to your deductible or out of pocket on your plan so you can have an idea of what YOUR cost may be ahead of time.

Stabler
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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.

Alibaba

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I don't have a code book to look up possible codes but I would suggest these diagnoses after ultrasound/dopplar/injection tests.
Scar formation subject to poor blood flow
Plague subject to poor blood flow.
Pain due to poor blood flow
Poor blood flow due to pelvic injury/or subject to x___x surgery
Peyronies due to plaque and scar tissue subject to poor inflow of blood

I think these should qualify for PDE5 inhibitors to assist. Worst case, Adcirca or the Viagra equivalent ( I do not know the name) for pulmonary hypertension if you can quantify it. That will get you 60) 20mg Cialis a month.
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Milam 1/13/16-LGX 21cm - BAD service & surgical outcome Hated infrapubic.
Kramer revision 3/1/17 Titan 22cm + 1.5 cm extenders
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