Will insurance pay for a penile implant?
Insurance cover for a penile implant depends on the plan, not on clinical guidelines. At one US tertiary centre in 2016 and 2017, Medicare insured 39.5% of men seeking an inflatable implant, while 48.0% of men with commercial insurance could not obtain the device because of plan exclusions or denials, despite a medical need for it.
What did the coverage study find?
A study at a tertiary care centre in Miami looked at 220 men who sought an inflatable penile implant between 2016 and 2017. Medicare was the most common insurer, covering 87 of the 220 men, or 39.5%.
Of the 127 men with commercial insurance, 61, or 48.0%, could not obtain the device because their plan excluded it or their claim was denied. Most of the commercially insured men had health maintenance organisation plans, at 62.6%, and 30.0% had preferred provider organisation plans. The most common reasons for seeking an implant were radical prostatectomy, at 30.9%, other physical causes of erectile dysfunction, at 30.5%, and diabetes, at 20.9%.
How has access to implant surgery changed in Medicare?
A separate study of Medicare claims found that the national rate of penile implant surgery fell from 5.41 per 1,000 beneficiaries with erectile dysfunction in 2006 to 3.74 per 1,000 in 2014, a decrease of 30.8%. Over the same period, the number of men diagnosed with erectile dysfunction grew faster than the number having surgery.
Access also varied by region. In 2014 the rate differed twelve-fold, from 1.9 per 1,000 in Norfolk, Virginia, to 24.2 per 1,000 in Miami, Florida, and adjusting for the number of urologists in each area reduced this to a 3.5-fold difference. Fewer than 24% of US urologists perform implant surgery.
Why can medical need and insurance cover differ?
Clinical guidelines set out who may benefit from an implant. The European guideline makes a strong recommendation for an implant when other treatments fail or when the patient prefers it, and the American guideline states that every man with erectile dysfunction should be told about the option.
Whether a particular plan pays is decided by the plan itself, which is why medical need and coverage can differ.
"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." Source 3, p. 155
The European guideline treats cost as one of the factors in a tailored plan for erectile dysfunction, alongside invasiveness, efficacy, safety and patient preference. It also reports that treatment costs are among the most common barriers to men using treatment for erectile dysfunction.
Coverage terms, exclusions and prior authorisation rules are set by each plan, so they are usually confirmed with the insurer and the surgeon's office before surgery is scheduled.