Baylor College of Medicine, Houston, Texas.
Urology of Virginia/Eastern Virginia Medical School, Virginia Beach, Virginia.
Urol Pract. 2023 Sep;10(5):501-510. doi: 10.1097/UPJ.0000000000000416. Epub 2023 Aug 18.
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.
评估了制造商的获益验证数据库，以确定美国对用于治疗勃起功能障碍的可植入阴茎假体的健康计划保险覆盖范围。
查询所有支付者和雇主赞助的健康计划获益验证数据库，以确定可植入阴茎假体的批准状态。对于所有支付者的分析，可获得按支付者划分的数据，并呈现 2019-2021 年的数据，以评估不同支付者和随时间推移的批准状态。对于雇主赞助的健康计划分析，可获得 2018-2021 年按支付者划分的数据。
2019 年、2020 年和 2021 年，全支付者数据库的获益验证记录分别可用于 3167 名患者、3016 名患者和 2837 名患者。保险类型为优选提供者组织（27.5%）、医疗保险优势计划（26.9%）、医疗保险（15.9%）或按服务点数付费计划（10.5%）。大多数患者获得可植入阴茎假体覆盖的批准或验证（2019 年为 79.4%、2020 年为 79.6%、2021 年为 78.4%）。基于政府的保险覆盖范围最广（医疗保险 98.7%、医疗保险优势计划 97.1%、Tricare 100%和退伍军人事务部 80.0%），但商业保险也有利（75.0%）。缺乏覆盖的最常见原因是雇主排除；由于排除而没有覆盖的患者比例从 2019 年的 13.5%增加到 2021 年的 17.5%。对雇主赞助的健康计划数据库（n=3083 名患者）的分析显示，63.1%的患者获得了覆盖范围的批准或验证，34.2%的患者由于健康计划排除而没有覆盖范围。
大约 80%的患者有可植入阴茎假体覆盖。雇主排除是导致覆盖范围滞后的最常见原因；2019-2021 年，雇主排除率增加了 29.3%。
