UPJ INSIGHT Implantable Penile Prosthesis for Erectile Dysfunction: Insurance Coverage in the United States

By: Mohit Khera, MD, MBA, MPH, Baylor College of Medicine, Houston, Texas; Joshua P. Langston, MD, Urology of Virginia/Eastern Virginia Medical School, Virginia Beach; Matthew E. Pollard, MD, Posterity Fertility, PC, Denver, Colorado; Denise Asafu-Adjei, MD, MPH, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois; Natalie C. Edwards, MSc, Health Services Consulting Corporation, Boxborough, Massachusetts; Krista D. Nitschelm, COC, PAHM, Health Economics & Market Access, Pelvic Floor & Prosthetic Urology, Boston Scientific Corporation, Marlborough, Massachusetts; Mital Patel, MD, Global Value & Outcomes, Boston Scientific Corporation, Marlborough, Massachusetts; Samir K. Bhattacharyya, PhD, Health Economics & Market Access, Boston Scientific Corporation, Marlborough, Massachusetts | Posted on: 19 Sep 2023

Khera M, Langston JP, Pollard ME, et al. Implantable penile prosthesis for erectile dysfunction: insurance coverage in the United States. Urol Pract. 2023;10(5):501-510.

Study Need and Importance

The extent of insurance coverage for implantable penile prostheses (IPPs) for erectile dysfunction (ED) has not yet been adequately ascertained; hence, it is unclear whether this is a barrier to access for IPP treatment. This study utilized a manufacturer’s benefit verification databases to ascertain insurance coverage for IPP for ED.

What We Found

IPP insurance coverage was most extensive for government-based insurance (Medicare 98.7%, Medicare Advantage 97.1%, Tricare 100%, and Veterans Affairs 80.0%) but was also favorable for commercial insurance (75.0%; see Figure). The most common reason for lack of coverage was employer exclusion; the proportion of patients with no coverage due to exclusion increased from 13.5% in 2019 to 17.5% in 2021. Analyses of the employer-sponsored health plan database (n=3,083 patients) showed that 63.1% of patients were approved or verified for coverage and 34.2% did not have coverage due to health plan exclusions.

Figure. Implantable penile prosthesis approval status for the all-payer cohort by type of insurance status. Case status meanings: Verified: medical benefits were verified, and the procedure is covered. Approved: the health plan approved a prior authorization for the procedure. No Coverage-Exclusion: the employer’s health plan excludes medical benefits through the employer-sponsored health plan for a penile prosthesis. Cancelled: A request was sent by the physician’s office to cancel the verification of benefits. Denied-Not Medically Necessary: the request for the procedure was denied for not being medically necessary. Material Not Provided: the insurance benefit verification process was unable to be continued as the medical documentation requested was not received from the provider’s office. No Coverage-Medicaid: the state Medicaid excludes coverage for penile prosthesis. EPO indicates exclusive provider organization; HMO, health maintenance organization; OAP, open access plus; POS, point-of-service; PPO, preferred provider organization; VA, Veterans Affairs.

Limitations

The data represent the cases that providers submitted to the manufacturer benefit verification system and may not be generalizable to all patients seeking IPP for ED. Also, retrospective databases may have clerical inaccuracies, coding errors, or missing data.

Interpretation for Patient Care

Approximately 80% of patients have IPP insurance coverage. Employer exclusion is the most common reason for lagging coverage, with rates of exclusion increasing 29.3% from 2019 to 2021. There may be a misnomer that plans will likely not cover IPP placement and a lack of awareness of available support in seeking coverage from benefit verification services.