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Home | Men's Health | Insurance

Questions about Medicare

  1. Does Medicare cover procedures that utilize American Medical Systems (AMS) products?
  2. What would a Medicare patient's copay be for procedures that utilize AMS products?
  3. Does Tricare or the VA cover penile prosthesis?
  4. Does my private insurance cover penile prosthesis?
  5. I have been denied a penile prosthesis by my insurance, what are my options?
  6. I have questions about my Medicare benefits, who can I contact?

1. Does Medicare cover procedures that utilize AMS products?
Medicare generally covers procedures that use AMS products when the patient meets medical necessity. Medicare has specific National Coverage Determinations (NCD) for two specific conditions that are often treated by AMS products:

Impotence

Medicare has a NCD for the Treatment of Impotence (230.4). This NCD states that penile prosthesis are a covered benefit when a patient meets medical necessity.

Incontinence

Medicare has a NCD for the Incontinence Control Devices (230.10). This NCD states that, “such a device is covered when its use is reasonable and necessary for the individual patient.”

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2. What would a Medicare patient's copay be for procedures that utilize AMS products?
Please click here to review Medicare patient copay estimates for procedures utilizing AMS products in the outpatient hospital or ambulatory surgical center settings.

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3. Does Tricare or the VA cover penile prosthesis?
Please click here to learn more on Tricare and Veterans Affairs coverage for penile prosthesis.

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4. Does my private insurance cover penile prosthesis?
AMS recommends that your doctor's office send a written letter of predetermination to your private insurance company. This letter should ask if you meet the medical necessity requirements for the procedure in addition to verifying your individual policy has coverage for this procedure. Insurance companies typically send a written response back informing you if you meet both requirements.

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5. I have been denied a penile prosthesis by my insurance, what are my options?

Please review some of options below that you might consider. First determine what type of denial you received.

  • Is the denial based on a contract exclusion?

Review your benefit information for specific exclusion language. Some types of contract exclusions include no payment for:

  • Sexual dysfunction
  • Impotence
  • Sexual inadequacy
  • Penile prosthesis
  • Penile implants

Review your benefit information for specific medical benefits such as:

  • Prosthetic devices
  • Reconstructive surgery
  • Surgery to repair body function

You have the right to appeal any denial from your health plan. In many cases, there is a time limit following the denial in which your appeal must be received. Check your benefit information or any denial letter you received for specific timelines.

My insurance still won't pay. What can I do?

You have gone through the entire appeal process and your insurance still won't pay. If the contract language has a clearly written exclusion, your insurance may legally continue to deny coverage. What are your remaining options?

Review other medical policies you may have.

  • Do you have Medicare?
  • Are you covered under a secondary plan by someone else, such as a spouse?
  • Have you served in the military and are covered under TriCare?
  • Do you qualify under Cobra to be part of another plan?
  • Is your health plan a self-funded program? Check with your Human Resource Department to determine whether you are covered under a self-funded program. Employers can make a final determination for coverage in self-funded plans. Request information on the process involved in having your request reviewed for coverage.

Explore the opportunity for open enrollment

  • This usually occurs at year end and may allow you to choose another health plan.
  • Determine whether another option is offered that may have benefits for erectile dysfunction and penile prostheses.
  • Determine whether you are able to upgrade your current plan by paying extra premiums (These are referred to as riders).

Consider self payment

Paying for your surgery out-of-pocket may not be the most desirable option. It may be your only option if you have exhausted all other options. Here are considerations that could make self payment more feasible:

  • Negotiate prices
  • Explore all of your options regarding where you have your procedure performed. If your health plan is not paying for any of the costs, then you are not obligated to follow any rules set by the health plan. You would not be limited to facilities in network. You may research prices at different facilities and negotiate a price you are the most comfortable with.
  • Utilize pre-tax flex spending plans.
  • Explore loan options.

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6. I have questions about my Medicare benefits, who can I contact?
You can contact AMS Health Care Affairs with questions at (888) 865-3373 regarding procedures that utilize AMS products. If you have other general questions or need help with your Medicare benefits there is FREE ASSISTANCE AVAILABLE. The State Health Insurance Assistance Program (SHIP) has counselors in every state and several territories that are available to provide FREE one-on-one help with your Medicare questions or problems. Click here to visit Medicare's website to locate a SHIP counselor in your area. Select SHIP from the Search by Organization Name dropdown to get started.

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600592-01C (07/11)