Commercial Insurance Coverage for Inflatable Penile Prosthesis at a Tertiary Care Center

John M. Masterson, Bruce Kava, Ranjith Ramasamy

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Introduction: Inflatable penile prosthesis has become an important treatment modality for men with erectile dysfunction that is refractory to medication. Despite high levels of patient satisfaction following inflatable penile prosthesis placement and inflatable penile prosthesis coverage by Medicare, coverage by commercial insurance providers is unknown. The purpose of this study was to determine the coverage of inflatable penile prosthesis by commercial insurance providers. Methods: Following institutional review board approval all men with erectile dysfunction interested in obtaining inflatable penile prosthesis at our tertiary care center between January 2016 and December 2017 were evaluated. We reviewed billing records for CPT code 54405 during the study period to evaluate the insurance provider for all men who received an inflatable penile prosthesis. We also reviewed a manually maintained record of excluded or denied inflatable penile prosthesis claims for men who desired inflatable penile prosthesis but could not obtain it. Through medical record review we recorded the etiology of erectile dysfunction and the specific type of insurance policy for each man. Results: Medicare is the most common insurer for inflatable penile prosthesis, insuring 87 of 220 (39.5%) men seeking inflatable penile prosthesis between 2016 and 2017. Among the remaining 127 men seeking inflatable penile prosthesis with commercial insurance coverage 61 (48.0%) were unable to obtain the device due to exclusions in their coverage or denials. Among commercially insured men seeking inflatable penile prosthesis 77 (62.6%) and 37 (30.0%) had health maintenance organization and preferred provider organization plans, respectively. The most prevalent indications for inflatable penile prosthesis among the entire study population were radical prostatectomy (30.9%), organic erectile dysfunction (30.5%) and diabetes mellitus (20.9%). Conclusions: The largest insurer for inflatable penile prosthesis in the Miami region is Medicare. While some patients seeking inflatable penile prostheses can receive insurance coverage, a large percentage (48.0%) are not able to receive coverage despite having a medical necessity for the treatment of erectile dysfunction.

Original languageEnglish (US)
Pages (from-to)155-158
Number of pages4
JournalUrology Practice
Volume6
Issue number3
DOIs
StatePublished - May 1 2019

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Penile Prosthesis
Insurance Coverage
Tertiary Care Centers
Erectile Dysfunction
Medicare
Insurance
Insurance Carriers
Preferred Provider Organizations
Current Procedural Terminology
Health Maintenance Organizations
Research Ethics Committees

Keywords

  • erectile dysfunction
  • insurance
  • penile prosthesis

ASJC Scopus subject areas

  • Urology

Cite this

Commercial Insurance Coverage for Inflatable Penile Prosthesis at a Tertiary Care Center. / Masterson, John M.; Kava, Bruce; Ramasamy, Ranjith.

In: Urology Practice, Vol. 6, No. 3, 01.05.2019, p. 155-158.

Research output: Contribution to journalArticle

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title = "Commercial Insurance Coverage for Inflatable Penile Prosthesis at a Tertiary Care Center",
abstract = "Introduction: Inflatable penile prosthesis has become an important treatment modality for men with erectile dysfunction that is refractory to medication. Despite high levels of patient satisfaction following inflatable penile prosthesis placement and inflatable penile prosthesis coverage by Medicare, coverage by commercial insurance providers is unknown. The purpose of this study was to determine the coverage of inflatable penile prosthesis by commercial insurance providers. Methods: Following institutional review board approval all men with erectile dysfunction interested in obtaining inflatable penile prosthesis at our tertiary care center between January 2016 and December 2017 were evaluated. We reviewed billing records for CPT code 54405 during the study period to evaluate the insurance provider for all men who received an inflatable penile prosthesis. We also reviewed a manually maintained record of excluded or denied inflatable penile prosthesis claims for men who desired inflatable penile prosthesis but could not obtain it. Through medical record review we recorded the etiology of erectile dysfunction and the specific type of insurance policy for each man. Results: Medicare is the most common insurer for inflatable penile prosthesis, insuring 87 of 220 (39.5{\%}) men seeking inflatable penile prosthesis between 2016 and 2017. Among the remaining 127 men seeking inflatable penile prosthesis with commercial insurance coverage 61 (48.0{\%}) were unable to obtain the device due to exclusions in their coverage or denials. Among commercially insured men seeking inflatable penile prosthesis 77 (62.6{\%}) and 37 (30.0{\%}) had health maintenance organization and preferred provider organization plans, respectively. The most prevalent indications for inflatable penile prosthesis among the entire study population were radical prostatectomy (30.9{\%}), organic erectile dysfunction (30.5{\%}) and diabetes mellitus (20.9{\%}). Conclusions: The largest insurer for inflatable penile prosthesis in the Miami region is Medicare. While some patients seeking inflatable penile prostheses can receive insurance coverage, a large percentage (48.0{\%}) are not able to receive coverage despite having a medical necessity for the treatment of erectile dysfunction.",
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N2 - Introduction: Inflatable penile prosthesis has become an important treatment modality for men with erectile dysfunction that is refractory to medication. Despite high levels of patient satisfaction following inflatable penile prosthesis placement and inflatable penile prosthesis coverage by Medicare, coverage by commercial insurance providers is unknown. The purpose of this study was to determine the coverage of inflatable penile prosthesis by commercial insurance providers. Methods: Following institutional review board approval all men with erectile dysfunction interested in obtaining inflatable penile prosthesis at our tertiary care center between January 2016 and December 2017 were evaluated. We reviewed billing records for CPT code 54405 during the study period to evaluate the insurance provider for all men who received an inflatable penile prosthesis. We also reviewed a manually maintained record of excluded or denied inflatable penile prosthesis claims for men who desired inflatable penile prosthesis but could not obtain it. Through medical record review we recorded the etiology of erectile dysfunction and the specific type of insurance policy for each man. Results: Medicare is the most common insurer for inflatable penile prosthesis, insuring 87 of 220 (39.5%) men seeking inflatable penile prosthesis between 2016 and 2017. Among the remaining 127 men seeking inflatable penile prosthesis with commercial insurance coverage 61 (48.0%) were unable to obtain the device due to exclusions in their coverage or denials. Among commercially insured men seeking inflatable penile prosthesis 77 (62.6%) and 37 (30.0%) had health maintenance organization and preferred provider organization plans, respectively. The most prevalent indications for inflatable penile prosthesis among the entire study population were radical prostatectomy (30.9%), organic erectile dysfunction (30.5%) and diabetes mellitus (20.9%). Conclusions: The largest insurer for inflatable penile prosthesis in the Miami region is Medicare. While some patients seeking inflatable penile prostheses can receive insurance coverage, a large percentage (48.0%) are not able to receive coverage despite having a medical necessity for the treatment of erectile dysfunction.

AB - Introduction: Inflatable penile prosthesis has become an important treatment modality for men with erectile dysfunction that is refractory to medication. Despite high levels of patient satisfaction following inflatable penile prosthesis placement and inflatable penile prosthesis coverage by Medicare, coverage by commercial insurance providers is unknown. The purpose of this study was to determine the coverage of inflatable penile prosthesis by commercial insurance providers. Methods: Following institutional review board approval all men with erectile dysfunction interested in obtaining inflatable penile prosthesis at our tertiary care center between January 2016 and December 2017 were evaluated. We reviewed billing records for CPT code 54405 during the study period to evaluate the insurance provider for all men who received an inflatable penile prosthesis. We also reviewed a manually maintained record of excluded or denied inflatable penile prosthesis claims for men who desired inflatable penile prosthesis but could not obtain it. Through medical record review we recorded the etiology of erectile dysfunction and the specific type of insurance policy for each man. Results: Medicare is the most common insurer for inflatable penile prosthesis, insuring 87 of 220 (39.5%) men seeking inflatable penile prosthesis between 2016 and 2017. Among the remaining 127 men seeking inflatable penile prosthesis with commercial insurance coverage 61 (48.0%) were unable to obtain the device due to exclusions in their coverage or denials. Among commercially insured men seeking inflatable penile prosthesis 77 (62.6%) and 37 (30.0%) had health maintenance organization and preferred provider organization plans, respectively. The most prevalent indications for inflatable penile prosthesis among the entire study population were radical prostatectomy (30.9%), organic erectile dysfunction (30.5%) and diabetes mellitus (20.9%). Conclusions: The largest insurer for inflatable penile prosthesis in the Miami region is Medicare. While some patients seeking inflatable penile prostheses can receive insurance coverage, a large percentage (48.0%) are not able to receive coverage despite having a medical necessity for the treatment of erectile dysfunction.

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KW - insurance

KW - penile prosthesis

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