Most common reason for lack of coverage is employer exclusion, which increased from 2019 to 2021
By Elana Gotkine HealthDay Reporter
THURSDAY, Aug. 24, 2023 (HealthDay News) — Most patients have coverage for implantable penile prosthesis for erectile dysfunction, with employer exclusion the most common reason for lacking coverage, according to a study published online in the Sept. 1 issue of Urology Practice.
Mohit Khera, M.D., M.P.H., from Baylor College of Medicine in Houston, and colleagues queried all-payer and employer-sponsored health plan benefit verification databases to determine implantable penile prosthesis approval status. Data were presented for 2019 to 2021 for the all-payer analysis (3,167 patients in 2019; 3,016 in 2020; and 2,837 in 2021) and from 2018 to 2021 for the employer-sponsored health plan analysis.
The researchers found that most patients from the all-payer analysis were approved or verified for implantable penile prosthesis coverage (79.4, 79.6, and 78.4 percent in 2019, 2020, and 2021, respectively). For government-based insurance, coverage was most extensive (98.7, 97.1, 100, and 80 percent for Medicare, Medicare Advantage, Tricare, and Veterans Affairs, respectively), but favorable coverage was also seen for commercial insurance (75.0 percent). Employer exclusion was the most common reason for lack of coverage. From 2019 to 2021, there was an increase in the proportion of patients with no coverage due to exclusion from 13.5 to 17.5 percent. Overall, 63.1 percent of the 3,083 patients in the employer-sponsored health plan database were approved or verified for coverage; 34.2 percent did not have coverage due to exclusions in the health plan.
“Our study raises concerns that some insurance plan policies are denying an effective, research-proven therapy, for a very common condition for which treatment is considered medically necessary,” Khera said in a statement.
Several authors disclosed ties to the pharmaceutical and medical device industries, including Boston Scientific, where several authors are employed.
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