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
Commercial insurance plans are typically purchased either individually or through an employer and may include options such as health maintenance organizations (HMOs), preferred provider organizations (PPOs), and high-deductible health plans (HDHPs).
Many insurance plans provide coverage for a testicular implant(s) if you meet the criteria for being a medically necessary treatment. Your doctor can help you understand these criteria.
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:
- Choose a product (Torosa)
- Select your state
- Choose your insurance plan
- Click on “View Payer Info” to see coverage highlights and link to policy details
If you don’t see your policy listed, don’t worry! It just means that the insurance plan may not have a policy specifically covering testicular implants. Your physician will review your coverage details during the benefits verification process.
Benefits verification is the process by which your physician’s office will verify the type of insurance plan you have and the effective dates, any medical policy guidance for the procedure, any relevant exclusions, and whether or not a prior authorization is required for your procedure.
Prior authorization requires healthcare providers to obtain approval from an insurance company before certain medications, treatments, or procedures can be covered based on your condition and the insurer’s guidelines.
While prior authorization for testicular implants does not guarantee that the procedure is covered, some insurance plans require it prior to the procedure.
During benefits verification, your physician’s office will also identify and provide an estimate for your out-of-pocket costs. To obtain this information, they will need your group policy number and the name of the policy holder.
If coverage for testicular implants is excluded, you will have the option to file for an exception.
If your plan does have an exclusion for testicular implants, you may be able to appeal the exclusion and get an exception. Exclusions are services and procedures not covered by your health plan.
If you prefer to appeal an exclusion with your insurance plan directly, reach out to your insurance representative and ask for instructions on how to submit the appeal request.
Be ready to provide supporting documentation that demonstrates the medical necessity of the procedure, which may include medical records, lab results, and notes from your urologist and other physicians such as your primary care physician.
You also have the right to appeal if your prior authorization request is denied.
If your prior authorization request is denied, 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.
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. Know that each insurance company can have multiple levels of appeals.
We have created a checklist to help guide you and your physician’s office in sending a complete and thorough appeal request to the insurance company: Appeals Checklist
You can also find helpful information on the Medicare website: How do I file an appeal?1
Depending on which state you reside in, you may have the option to utilize the Consumer Assistance Program. This tool also has quick access to State Insurance Boards as sometimes appeals to coverage can be external.
In addition, our Reimbursement and Benefits Team can assist you and your physician with the appeals process: 1-855-230-7611.
Understanding insurance coverage
Remember: coverage varies by insurance plan. To see if your plan covers this procedure, explore our interactive map.
If you don’t see your policy listed, don’t worry! It just means that the insurance plan may not have a policy specifically covering testicular implants.
I have Medicare / Medicare Advantage
Medicare (also known as original Medicare) consists of two main parts:
- Medicare Part A: This provides coverage for inpatient hospital care, skilled nursing facility care, hospice care, and some home health care services.
- Medicare Part B: This covers certain doctor’s services, outpatient care, medical supplies, and preventive services.
If you have the red, white, and blue card, you have original Medicare.
Medicare typically covers medically necessary procedures, including testicular implants, when deemed appropriate by a healthcare provider, without requiring prior authorization (obtaining approval from the insurance company before certain procedures can be covered).
A testicular implant procedure is typically performed under outpatient status. That means it will likely be covered by Medicare Part B, where your responsibility would be 20% of your cost of care. If you have supplemental insurance, you may have the additional 20% coinsurance covered by the secondary plan.
Medicare Advantage plans are a little different.
Medicare Advantage plans provide the same coverage as original Medicare (Parts A and B) along with the option to include additional benefits, such as prescription drug coverage.
These managed Medicare plans are offered through private insurance companies approved by Medicare. These plans may have policies for prior authorization (approval from the insurance company before certain procedures can be covered) or pre-determination (confirmation of coverage before a procedure is performed, to allow patients and providers to understand coverage details in advance and anticipate potential out-of-pocket costs).
Costs and coverage for testicular implants under Medicare Advantage plans can vary depending on the specific plan. These plans have to cover at least what original Medicare covers; however, unlike original Medicare, these plans may place restrictions on coverage such as prior authorization.
You can visit the Medicare website to learn more about what Medicare covers,2 and download the Medicare and You handbook3 (PDF) for a detailed review of Medicare coverage.
It’s essential to review the details of your plan to understand what is covered and any associated costs. Please consult with your healthcare provider and insurance plan to clarify coverage options and eligibility criteria.
I have Medicaid / Managed Medicaid
Medicaid coverage for testicular implants varies a great deal between states and by individual circumstances. In some states, Medicaid does not provide coverage for testicular implants.
In other states, Medicaid provides coverage for medically necessary procedures, including testicular implants, for eligible individuals. Of the states where Medicaid does provide coverage for testicular implants, some may require prior authorization (approval from the insurance company before certain procedures can be covered).
In some states, Medicaid may cover the implant itself but not necessarily associated costs such as facility fees or surgeon fees.
Please consult with your healthcare provider and the Medicaid program to understand coverage details and eligibility criteria.
I am paying without insurance
If you are paying for your testicular implant yourself, try to determine if and how you can best decrease the costs before you have the procedure.
First, find out how your physician charges for their services.
- Many physician’s offices offer self-pay options that may save you money.
- Having your procedure at a surgery center instead of a hospital may result in lower facility costs.
Your physician’s office may be the best resource for financial and savings options, so don’t hesitate to reach out to them.
Next, consider exploring additional savings and credit options to help you balance the costs most effectively for your situation.
A Health Savings Account (HSA) can help you save money and pay for healthcare expenses tax-free. HSAs are available with high deductible health insurance plans.
You can save money in your HSA account before taxes and use the funds to pay for eligible healthcare expenses. This may include healthcare expenses your plan doesn’t cover.
Healthcare Credit Cards can provide an option for payment when you need health care services or procedures and can’t pay for them right away or the services and procedures you seek may not be covered by insurance.
This option allows you to get the treatment you need without delay. The card issuer pays the charges up front, while you can pay a little bit each month to get the necessary treatment while being able to manage the expense.
Various companies offer healthcare credit cards. If you would like to pursue paying for your procedure with a healthcare credit card, ask your physician if this may be an option.
Frequently asked questions
How do I know if I have coverage?
To determine if you have insurance coverage for a testicular 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 (Torosa)
2. Select your state
3. Choose your insurance plan
4. Click on “View Payer Info” to see coverage highlights and link to policy details
What does “medically necessary” mean and why is it important?
“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 testicular implant if it is deemed medically necessary by your healthcare provider.
A testicular implant may be considered a medically necessary treatment for you depending on the reason you are missing your testicle.
What is a prior authorization request?
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.
Some insurance plans, including some Medicare Advantage plans and Medicaid coverage in some states, may require prior authorization request before providing coverage for a testicular implant procedure.
Why would an insurance plan deny my prior authorization?
There are a few reasons why your health plan may deny your proposed treatment, including:
• Services are not considered medically necessary or appropriate in a specific healthcare setting or level of care
• The health plan considers the treatment to be investigational, experimental or unproven
• The service requested is not a covered benefit under the plan
What do I do if my prior authorization is denied?
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 appeal.
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.
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 Support Team is here to help. We’re available 9am-4pm CST. Give us a call today.
Find a local implant doctor
If you are ready to talk to a doctor about the possibility of receiving a testicular implant(s), use our physician directory to find a qualified urologist specializing in testicular replacement near you. They can answer your questions and help you take the next step toward feeling like yourself again.
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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