ISSN: 2578-4676
Authors: Service CA, Greear GM, Walia A, Edwards NC, Nitschelm KD, Bhattacharyya S4 and Hsieh TC*
Introduction: Many commercial insurers and Medicare have published coverage policies detailing the medical necessity and accessibility of erectile dysfunction (ED) treatment, including implantable penile prosthesis (IPP). Approximately 61% of adults aged 18–64 years in the United States (US) receive health benefits via employer-sponsored health plans (ESHP) and 23% of employers reported medical benefit exclusion for sexual dysfunction treatment. Objective: To obtain nationwide US estimates of the proportions of patients denied IPP treatment due to ESHP exclusions (overall and by state, healthcare insurer, and labor sector industry). Methods: De-identified data from an industry IPP insurance benefit verification database from October 1, 2018 to December 31, 2021 were analyzed to evaluate ESHP-related barriers to IPP access. Results: Among 2,638 patients with commercial insurance and employer data, 34.0% were denied IPP treatment due to ESHP benefit exclusions. ESHPs in Washington (60.7%), Louisiana (55.4%), Arizona (46.6%), Nebraska (45.5%), Ohio (43.3%), and Georgia (43.1%) had the highest exclusion rates, whereas Iowa (19.0%), Alabama (18.9%), Maryland (17.3%), Rhode Island (13.0%), and New York (7.1%) had the lowest exclusion rates. Patients with Aetna insurance had the greatest proportion of exclusions (62.4%), followed by Cigna (61.0%), employer-owned health plans (47.2%), other commercial plans (41.8%), Anthem (37.3%), Blue Cross Blue Shield (BCBS) state plans (24.1%), United Healthcare (15.4%), and Humana (0.0%). The exclusion rate was highest for employees of the leisure and hospitality industry (51.9%), followed by religious organizations (50.0%), health care (40.5%), construction, mining, or agriculture (39.1%), education (38.9%), retail and wholesale trade (36.9%), manufacturing (36.7%), utilities (36.2%), professional and business services (35.4%), transportation (32.6%), finance and insurance (29.1%), labor union organizations (26.9%), and finally public, state, and government administration (25.1%). Conclusions: Despite insurance carrier medical policies, 34.0% of men with an ESHP are denied access to IPP ED treatment due to their ESHP benefit exclusions. ESHP exclusion rates varied geographically, by insurer, and by labor sector industry.
Keywords: Penile; Erectile; Health; Exclusions; Dysfunction
