To determine the degree of transparency of health insurer policies regarding coverage of male sexual health conditions, we examined the publicly available policy coverage documents of the largest US medical insurance plans.
We selected two index patients across the male sexual health spectrum: (1) a PDE5 refractory erectile dysfunction patient requiring intracavernosal injection therapy or penile prosthesis, (2) a 50 yo male patient with laboratory-confirmed, symptomatic hypogonadism requiring testosterone replacement therapy as defined by endocrine society criteria. We researched the policy documents regarding coverage for standard therapies. We used breast reconstruction after mastectomy as a control.
We queried the publicly available policy statements for 84 of the largest health care plans in the United States. While breast reconstruction policies are publicly available for 94% of plans examined, policies of only 39% of plans for advanced ED treatment options and 62% for hypogonadism are publicly available. Of the plans that had publicly accessible data for erectile dysfunction coverage, 85% viewed penile prosthesis and intracavernosal injection as medically necessary, while 91% of viewed androgen replacement as medically necessary for our index patient.
There is a lack of transparency among medical insurers regarding coverage of ED and hypogonadism in stark contrast to reconstructive breast surgery.
Urology. 2016 Dec 23 [Epub ahead of print]
Brian V Le, Sarah McAchran, David Paolone, Daniel R Gralneck, Daniel Williams, Wade Bushman
Department of Urology, University of Wisconsin-Madison, Madison, WI. Electronic address: ., Department of Urology, University of Wisconsin-Madison, Madison, WI.