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.
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.