Do Blue Cross Insurance Plans Cover Penile Implant surgery?


If you have any questions, to schedule a consultation or if you need a second opinion, please contact us or call 1-(646) 663-5211.    Please contact us to verify your insurance coverage of penile implant.

Our urologists are experienced surgeons who offer inflatable 3-piece penile prosthesis, semi-rigid penile implant and other treatment options for ED.


Penile Prosthesis Coverage By Blue Cross Plans

There are many different Blue Cross plans and each plan is a little different.  In general, most Blue Cross commercial PPO and HMO plans including Anthem Blue Cross, Empire BCBS, Horizon BCBS , CareFirst Blue Cross, Highmark BC, Blue Cross of Texas, BC of California, Blue Cross of Illinois, BC of Florida and other Blue Cross plans have coverage for penile implantation surgery for men with organic erectile dysfunction.

shutterstock_115676002In general, pre-authorization and documentation of erectile dysfunction are necessary for the insurance company to approve penile prosthesis surgery.  Typically, this involves sending urologist’s notes about prior treatment and diagnostic evaluation including diagnosis (ICD10 codes).

Typically, penile implant surgery is covered by Blue Cross plans for patients who do not respond to oral therapy with medications such as Viagra, Cialis, Levitra or Stendra or who have a contraindication to these medications.

While many plans do not cover medications for ED such as Viagra (sildenafil), Cialis, Levitra, and Stendra, most plans cover the costs of penile prosthesis surgery.  Benefits vary from plan to plan and need to be verified.

Typical criteria for coverage of penile implant by Blue Cross insurance plans include the following:

Neurogenic impotence of greater than one-year duration due to one of the following:

  • Spinal cord injury/disease;
  • Multiple Sclerosis;
  • Spina Bifida;
  • Diabetes;
  • Radical prostatectomy;
  • Rectal surgery;
  • Fractured pelvis.

Vasculogenic (vascular) impotence of greater than one-year duration due to one of the following:

  • Intrapenile arterial disease;
  • Status post cavernosal infection;
  • Peyronie’s disease;
  • Penile contusion;
  • Hypertension;
  • Penile fracture;
  • Smoking.

Patients with other causes of erectile dysfunction may also qualify for penile implant surgery.

If you want to verify benefits, you can call your insurance company

The phone number is located on the back of your insurance card and provide them with the following codes:

Commonly used ICD10 Diagnostic Codes:

  • N52.01 Erectile dysfunction due to arterial insufficiency

Commonly Used CPT Procedure codes:

  • 54400  Insertion of a penile prosthesis; non-inflatable (semi-rigid)
  • 54401  Insertion of a penile prosthesis; inflatable (self-contained)
  • 54405  Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir
  • 54410  Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session
  • 54411  Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue
  • 54416  Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session
  • 54417  Removal and replacement of a non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue

HCPCS

  • C1813 Prosthesis, penile, inflatable
  • C2622 Prosthesis, penile, non-inflatable
  • L8699  Prosthetic implant, not otherwise specified

ICD-10 Procedure

  • 0VUS0JZ         Supplement penis with synthetic substitute, open approach
  • 0VUS4JZ         Supplement penis with synthetic substitute, percutaneous endoscopic approach

 

What You Need to Know:

Learn More About:


If you have any questions, to schedule a consultation or if you need a second opinion, please contact us or call 1-(646) 663-5211.

We offer affordable, highest-quality urology care with or without insurance.   Find out our office hours or directions to our office. We offer weekday, weekend and evening office hours.

Dr. Alex Shteynshlyuger is a board-certified urologist, who specializes in all aspects of care for sexual problems in men including ED, premature ejaculation and other sexual concerns.  He has successfully treated hundreds of men with sexual problems including ED and poor libido. We see patients from all parts of New York City (Manhattan, Brooklyn, Queens, Bronx, Staten Island), Long Island, Westchester and New Jersey as well as other parts in the USA, Canada, South America and the Caribbean and other international patients. We also offer emergency care for men with urological problems.


 

Top