An assessment of current penile prosthesis reimbursement guidelines for insurance plans nationwide

Abstract

A lack of uniformity exists for insurance payer coverage for all categories of penile prostheses (PP). We sought to determine common insurance coverage criteria and barriers to implantation across common insurance plans from healthcare referral regions (HRR) nationwide. Coverage criteria and stipulations were reviewed regarding erectile dysfunction (ED) etiology, ED duration, contributing comorbid conditions, medications, drug use, diagnostic tests, use of procedures and prior interventions. Seventy of 100 plans included coverage criteria. 36.1% provided coverage only in cases of gender dysphoria. 27.7% required documentation of trial, contraindication or intolerance to pharmacologic therapy, with varying descriptors of what this entailed. 13.8% required at least consideration of prior pharmacologic therapy. 4.2% required trial or contraindication to classic second-line therapies. 25.0% stated that ED must be organic. Psychogenic ED was covered by 12.5% of plans. Eleven plans required at least 6 or 12 months of symptoms. Laboratory evaluation to rule out hypogonadism or hyperprolactinemia was required by five plans. Insurance coverage criteria for PP placement were highly variable by state and plan. Coverage is provided for PP implantation in most cases for ED of organic etiology following failure of pharmacologic therapy when contributing comorbidities are optimally managed.