Masterson John M, Kava Bruce, Ramasamy Ranjith
Department of Urology, University of Miami Miller School of Medicine, Miami, Florida.
Urol Pract. 2019 May;6(3):155-158. doi: 10.1016/j.urpr.2018.07.002.
Inflatable penile prosthesis has become an important treatment modality for men with erectile dysfunction that is refractory to medication. Despite high levels of patient satisfaction following inflatable penile prosthesis placement and inflatable penile prosthesis coverage by Medicare, coverage by commercial insurance providers is unknown. The purpose of this study was to determine the coverage of inflatable penile prosthesis by commercial insurance providers.
Following institutional review board approval all men with erectile dysfunction interested in obtaining inflatable penile prosthesis at our tertiary care center between January 2016 and December 2017 were evaluated. We reviewed billing records for CPT code 54405 during the study period to evaluate the insurance provider for all men who received an inflatable penile prosthesis. We also reviewed a manually maintained record of excluded or denied inflatable penile prosthesis claims for men who desired inflatable penile prosthesis but could not obtain it. Through medical record review we recorded the etiology of erectile dysfunction and the specific type of insurance policy for each man.
Medicare is the most common insurer for inflatable penile prosthesis, insuring 87 of 220 (39.5%) men seeking inflatable penile prosthesis between 2016 and 2017. Among the remaining 127 men seeking inflatable penile prosthesis with commercial insurance coverage 61 (48.0%) were unable to obtain the device due to exclusions in their coverage or denials. Among commercially insured men seeking inflatable penile prosthesis 77 (62.6%) and 37 (30.0%) had health maintenance organization and preferred provider organization plans, respectively. The most prevalent indications for inflatable penile prosthesis among the entire study population were radical prostatectomy (30.9%), organic erectile dysfunction (30.5%) and diabetes mellitus (20.9%).
The largest insurer for inflatable penile prosthesis in the Miami region is Medicare. While some patients seeking inflatable penile prostheses can receive insurance coverage, a large percentage (48.0%) are not able to receive coverage despite having a medical necessity for the treatment of erectile dysfunction.
可膨胀阴茎假体已成为药物治疗无效的勃起功能障碍男性的一种重要治疗方式。尽管可膨胀阴茎假体植入后患者满意度较高，且医疗保险也涵盖了可膨胀阴茎假体，但商业保险提供商的覆盖情况尚不清楚。本研究的目的是确定商业保险提供商对可膨胀阴茎假体的覆盖情况。
在获得机构审查委员会批准后，对2016年1月至2017年12月期间在我们三级医疗中心有兴趣获得可膨胀阴茎假体的所有勃起功能障碍男性进行了评估。我们审查了研究期间CPT代码54405的计费记录，以评估所有接受可膨胀阴茎假体男性的保险提供商。我们还审查了一份人工维护的记录，记录了那些想要可膨胀阴茎假体但无法获得的男性被排除或拒绝的可膨胀阴茎假体索赔情况。通过病历审查，我们记录了每位男性勃起功能障碍的病因和具体保险政策类型。
医疗保险是可膨胀阴茎假体最常见的承保方，在2016年至2017年期间寻求可膨胀阴茎假体的220名男性中，有87名（39.5%）由医疗保险承保。在其余127名寻求商业保险覆盖的可膨胀阴茎假体男性中，有61名（48.0%）因保险范围排除或被拒而无法获得该设备。在寻求可膨胀阴茎假体的商业保险男性中，分别有77名（62.6%）和37名（30.0%）拥有健康维护组织和优选提供者组织计划。在整个研究人群中，可膨胀阴茎假体最常见的适应症是根治性前列腺切除术（30.9%）、器质性勃起功能障碍（30.5%）和糖尿病（20.9%）。
迈阿密地区可膨胀阴茎假体最大的承保方是医疗保险。虽然一些寻求可膨胀阴茎假体的患者可以获得保险覆盖，但很大一部分（48.0%）尽管有治疗勃起功能障碍的医疗需求却无法获得覆盖。
