A manufacturer's benefit verification database was evaluated to ascertain United States health plan insurance coverage for implantable penile prostheses for erectile dysfunction.
All-payer and employer-sponsored health plan benefit verification databases were queried to determine implantable penile prosthesis approval status. For the all-payer analysis, data by payer were available and presented for 2019-2021 to assess approval status varied by payer and over time. For the employer-sponsored health plan analysis, data by payer were available from 2018-2021.
Benefit verification records for the all-payer database were available for 3,167 patients in 2019, 3,016 in 2020, and 2,837 in 2021. Insurance type was preferred provider organization (27.5%), Medicare Advantage (26.9%), Medicare (15.9%), or point-of-service (10.5%). Most patients were approved or verified for implantable penile prosthesis coverage (79.4% in 2019, 79.6% in 2020, and 78.4% in 2021). 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%). 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.
Approximately 80% of patients had implantable penile prosthesis coverage. Employer exclusion was the most common reason for lagging coverage; rates of employer exclusion increased 29.3% from 2019-2021.
Urology practice. 2023 Aug 18 [Epub]
Mohit Khera, Joshua P Langston, Matthew E Pollard, Denise Asafu-Adjei, Natalie C Edwards, Krista D Nitschelm, Mital Patel, Samir K Bhattacharyya
Baylor College of Medicine, Houston, Texas., Urology of Virginia/Eastern Virginia Medical School, Virginia Beach, Virginia., Posterity Fertility, PC, Denver, Colorado., Loyola University Chicago Stritch School of Medicine, Maywood, Illinois., Health Services Consulting Corporation, Boxborough, Massachusetts., Health Economics & Market Access, Pelvic Floor & Prosthetic Urology, Boston Scientific Corporation, Marlborough, Massachusetts., Global Value & Outcomes, Boston Scientific Corporation, Marlborough, Massachusetts., Health Economics & Market Access, Boston Scientific Corporation, Marlborough, Massachusetts.