Original Medicare and Medicare Advantage cover a penile implant if a doctor believes it to be medically necessary. There may be out-of-pocket costs to consider.
The implant makes the penis erect, which enables the person to have penetrative sex. As the medical community views surgery as a last resort, doctors may recommend other treatments first.
This article discusses Medicare’s coverage of penile implants and examines the possible causes of erectile dysfunction (ED). It also looks at other ED treatments and how Medicare might cover them.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Original Medicare comprises Part A, which is inpatient hospital insurance, and Part B, which is outpatient medical insurance.
Coverage of penile implants typically falls under Part B due to the procedure taking place in an outpatient setting.
Part B costs
The costs involve a 20% coinsurance once a person has paid their yearly deductible.
In 2021, the Part B deductible is $203.
Private health insurance companies administer Medicare Advantage plans, which are an alternative to original Medicare. These plans include all the benefits of parts A and B, including those relating to penile implants.
Medicare Advantage costs
The costs of Medicare Advantage plans include deductibles, copayments, and coinsurance, all of which vary depending on the plan provider.
As these costs vary, a person may wish to speak with their plan provider about what expenses to expect before they undergo a procedure.
Medigap is Medicare supplement insurance that is available to someone with original Medicare. It pays 50–100% of the out-of-pocket costs of parts A and B, including those for a penile implant.
ED, which people sometimes refer to as impotence, is a male’s inability to get or maintain an erection during sex.
According to a scientific review in Current Opinion in Nephrology and Hypertension, an estimated 30 million males in the United States have ED.
The following health conditions can lead to ED:
- multiple sclerosis
- high blood pressure
- atherosclerosis, which is the buildup of fatty deposits of plaque in the arteries
- heart and blood vessel disease
- type 2 diabetes
- chronic kidney disease
- Peyronie’s disease, which causes the penis to curve upon erection due to plaque buildup
In some cases, ED may result from an event, such as surgery for bladder cancer, damage from prostate cancer treatments, or an injury to the penis, prostate, bladder, or spinal cord.
Other factors may also contribute to ED, including:
When a person with ED first seeks medical attention, a doctor may suggest:
- getting regular exercise
- limiting or stopping alcohol consumption
- reaching or maintaining a moderate weight
- quitting smoking
Before prescribing medication, a doctor may also advise counseling to address anxiety. In some cases, they might change a medication that could be contributing to the condition.
If the initial measures do not produce the desired results, the doctor may prescribe treatment, such as oral medication or injections.
They may also recommend using a vacuum device, but surgery is an option if these treatments do not work well.
Medications by mouth
Oral ED drugs relax the smooth muscle tissue, promoting blood flow to the penis during sexual stimulation. These actions help produce an erection.
The available medications include:
- sildenafil (Viagra)
- tadalafil (Cialis)
- vardenafil (Levitra)
- avanafil (Stendra)
If a person has low levels of testosterone, a doctor may also prescribe this hormone.
Sometimes, a doctor may recommend an injectable treatment or a suppository.
Injecting a drug called alprostadil into the penis can increase the flow of blood, causing an erection. Alternatively, inserting a suppository of this drug into the urethra has the same effect.
A vacuum device pulls blood into the penis, and it helps maintain the erection by keeping the blood from flowing back into the body.
Doctors view surgical procedures as a last resort for most people, but if they confirm surgery as medically necessary, Medicare may cover it.
One type of surgery involves implanting a device called a prosthesis into the penis.
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) state that a person should be able to use the implant 4–6 weeks after the surgery.
There are two varieties: inflatable and malleable. An inflatable implant makes the penis broader and longer, whereas a malleable implant is a rod that a person can use to change the penis position manually.
The other type of surgery is artery reconstruction to restore blood flow that results from a blockage.
According to the NIDDK, those younger than 30 years are typically the preferred candidates for this option.
Medicare may cover diagnostic tests and some treatments for ED. It does not cover standard drugs, such as Viagra, for the condition, although some Medicare Advantage plans may cover them as an extra benefit.
Sometimes, a doctor may prescribe an ED drug for another condition, such as pulmonary hypertension, and Medicare does cover these prescriptions.
A person may get a drug plan in one of two ways. If they have original Medicare, they may buy Part D, which is prescription drug coverage. Someone with Medicare Advantage may not buy Part D, but they can choose an Advantage plan that includes drug benefits.
Medicare does provide coverage for penile implants. In original Medicare, coverage comes from Part B, where a person pays a 20% coinsurance after they have paid their annual deductible of $203.
The costs in Medicare Advantage plans include deductibles, coinsurance, and copayments, all of which vary.
Before recommending an implant for a person with erectile dysfunction, a doctor may suggest lifestyle changes or specific medications.
Medicare does not generally cover drugs for ED, such as Viagra, but some Medicare Advantage plans may cover them as an extra benefit.
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