Payment and insurance options

When it comes to undergoing a medical procedure, cost matters. Understanding those costs, along with your insurance benefits and coverage options, can help you be prepared. For tips and guidance on next steps, select the option below that best aligns with your current situation.

I have commercial insurance

I have Medicare / Medicare Advantage

I have Medicaid / Managed Medicaid

I am paying without insurance

Frequently asked questions

To determine if you have insurance coverage for a penile implant procedure, review your insurance policy documents or contact your insurance provider directly. Check for details such as coverage limits, deductibles, and covered services or events. If you’re unsure, your
insurance agent or representative can provide clarification.

Coverage varies by insurance plan. If you want to see if your plan covers this procedure, explore our interactive map to find initial info with just a few clicks:

  1. Choose a product
  2. Select a state
  3. Choose your insurance plan
  4. Click on “View Payer Info” to see coverage highlights and link to policy details

You can also review this brief and informative video showing how to verify your coverage and take actionable steps to help move the process forward: Understanding insurance coverage.

“Medically necessary” refers to healthcare services or treatments that are deemed essential to diagnose, treat, or manage a patient’s medical condition or symptoms.

For insurance companies, determining medical necessity helps control costs by ensuring that coverage is provided only for services that are essential for a patient’s health.

For patients, it’s important because many insurance plans, including some Medicare Advantage plans, will cover a penile implant if it is deemed medically necessary by your healthcare provider.

A penile implant may be considered a medically necessary treatment for erectile dysfunction (ED) if:

  • You have tried other non-invasive treatments (e.g., oral medications, penile injections) and found them to be ineffective.
  • Your ED is the result of an organic (medical) cause, rather than psychogenic (emotional) cause.
  • Your doctor can help you further understand these criteria.

This process requires healthcare providers to obtain approval from the insurance company before performing a specific treatment, procedure, or prescribing a medication.

It ensures that the proposed service meets the insurer’s criteria for coverage, including medical necessity and appropriateness. While prior authorization for a penile implant does not guarantee that the procedure is covered, some insurance plans require it prior to the procedure.

Most insurance plans, including some Medicare Advantage plans and Medicaid coverage in some states, may require prior authorization before providing coverage for a penile implant procedure.

There are a few reasons why your health plan may deny your proposed treatment, including:
  • Services are not considered medically necessary or your office did not provide sufficient documentation proving medical necessity.
  • The health plan considers the treatment to be investigational, experimental or unproven.
  • The service requested is not a covered benefit under the plan.

You have the right to file an appeal. This is when you ask for a full and fair review of the decision, aiming to overturn the denial and obtain approval for the procedure. Insurance plans often have multiple levels of appeals, and they may have differing appeal timelines that they will communicate to you.

Appeals give you the opportunity to present additional information, such as medical evidence or documentation, to support the necessity and appropriateness of the requested service, with the goal of securing coverage.

This checklist can help guide you and your physician’s office in sending a complete and thorough appeal request to the insurance company: Appeals Checklist

If your state has a Consumer Assistance Program, they may also help file an appeal on your behalf.

In addition, our Reimbursement and Benefits Team can assist you and your physician with the appeals process: 1-855-230-7611.

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Need help navigating the process?
Talk to an expert.

Navigating insurance benefits and coverage options can feel overwhelming. If you have questions about insurance coverage, our Reimbursement & Benefits Resources Team is here to help. We’re available 9-4 CST. Give us a call today.

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Find a local implant doctor

If you are ready to talk to a doctor about the possibility of receiving a penile implant, use our physician directory to find a qualified urologist specializing in ED near you. They can explain your options, answer your questions, and help you take the next step toward reclaiming control—and your confidence.

Get updates tailored for you

Your journey through ED is personal – and deserves personalized support. Simply take this brief, discreet online assessment to receive information, insights and support tailored for you and your unique journey.

Coloplast Corp. provides this information for your convenience only and makes no guarantees, expressed or implied, concerning the accuracy or appropriateness for any particular use of the information provided. It is intended for informational purposes for FDA approved uses only, and is not intended as a recommendation regarding clinical practice. A verification of benefits from Coloplast does not guarantee payment.

References

  1. How Do I File an Appeal? Medicare.gov. https://www.medicare.gov/claims-appeals/how-do-i-file-an-appeal. Accessed June 2024.
  2. What Medicare Covers. Medicare.gov. https://www.medicare.gov/what-medicare-covers. Accessed June 2024.
  3. Medicare and You Handbook. Medicare.gov. https://www.medicare.gov/publications/10050-Medicare-and-You.pdf. Accessed June 2024.
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