Is Penile Plication Covered by Insurances?
Penile plication procedures such as 16-dot-plication and Nesbit plication are typically covered by healthcare insurance plans such as Cigna, AETNA, UnitedHealthcare, Oxford, Blue Cross Blue Shield plans if it is performed to correct a functional problem that interferes with bodily functions.
In case of Peyronie’s disease and congenital penile curvature, penile plication is typically covered if a patient has pain with erections, difficulty with having intercourse or inability to have intercourse.
Penile plication is typically not covered by insurance companies if it is performed for the sole reason of improving the cosmetic appearance of the penis in a patient who does not have a functional problem.
It is always a good idea to verify insurance coverage before the procedure and if necessary appeal denial of coverage decision prior to having penile plication surgery.
Warning: Insurances love to deny penile plication inappropriately. Often, an appeal of their initial decision is necessary for them to approve the procedure.
At New York Urology Specialists, we work with your insurance to pre-authorize surgery to ensure that your insurance pays for the procedure. We appeal insurance denials on your behalf as well.
What is Necessary for Insurance to Approve Penile Plication?
Insurance may require that patients try another therapy such as injection therapy with Xiaflex or verapamil prior to approving penile plication.
Evaluation usually involves induction of penile erection with measurement of penile curvature as well as penile Doppler ultrasound to evaluate the penile anatomy and vascular function. Evaluation of erection quality is also part of this process. Insurances typically want to see that a patient undergoes a full evaluation to determine if alternative therapy is appropriate.
One of the required criteria for surgical treatment of Peyronie’s disease is that the disease process is fairly stable – there should be no new changes in curvature in the past 6 months.