- Medicare covers penile implant surgery when it’s necessary for the treatment of erectile dysfunction.
- Medicare Part B and Part C both cover outpatient procedure costs and follow-up visits.
- Medicare Part D is required to help cover any prescription drugs you need after the surgery.
- Out-of-pocket costs include any premiums or deductibles for your plan and coinsurance for the procedure and any prescription drugs.
Erectile dysfunction (ED) is a potential side effect of many health conditions, including cardiovascular disease, high blood pressure, low testosterone, and more.
Penile implant surgery is an ED treatment that can allow someone with ED to have an erection.
Medicare covers a penile implant when it’s deemed medically necessary for the treatment of ED.
This article explores what Medicare covers for penile implant surgery, out-of-pocket costs for the procedure, and what to expect when going in for surgery.
All Medicare plans include both hospital and medical insurance. With original Medicare, this refers to parts A and B.
Medicare Part A covers hospital insurance, which includes services such as:
Medicare Part B covers medical insurance, which includes:
- preventive services
- diagnostic and treatment services
- durable medical equipment (DME)
- mental healthcare
- clinical research
- certain outpatient drugs
- emergency room visits
- emergency ambulance transportation
Medicare Part C, also called Medicare Advantage, covers all services included under original Medicare. These plans often offer additional coverage as well, such as prescription drug coverage and other health perks.
Medicare Part D, an add-on to original Medicare, helps cover the cost of prescription medications that aren’t administered directly by a doctor.
How each part applies to penile implant surgery
Medicare will cover penile implant surgery if your doctor has decided that it’s medically necessary for ED in your case.
Penile implant surgery is considered an outpatient procedure, meaning that Medicare Part B typically covers it. Part B covers any doctor’s or specialist’s visits before, during, and after the procedure, as well as any medications administered directly by your doctor.
Pain medications and antibiotics will be covered under your Medicare Part D plan. If you don’t have prescription drug coverage with your Medicare plan, you’ll pay 100 percent of the medication costs out of pocket.
If you require an inpatient hospital stay after the procedure to treat an infection or other complication, Medicare Part A will cover it. However, most postsurgery complications can be handled by your primary care physician.
If you have a Medicare Part C plan, specific coverage for penile implant surgery will depend on your plan.
For example, some Medicare Advantage HMO and PPO plans have coverage networks that determine how much you pay out of pocket for your services. In addition, your prescription drug coverage may vary depending on your plan.
Before you move forward with scheduling this procedure, make sure your doctor or surgeon accepts Medicare assignment. If you’re not sure whether they do, Medicare’s provider search tool can help you find local physicians who participate in Medicare.
Medicare will cover your penile implant surgery if it’s medically necessary for the treatment of your condition. Penile prosthetics are currently approved to treat the following two medical conditions:
- ED, which is characterized by the inability to maintain or get an erection
- Peyronie’s disease, which is a form of ED characterized by painful or curved erections
Generally, your doctor will only approve — and Medicare will only cover — penile implant surgery for the above conditions if previous medical interventions have failed.
These include nonsurgical interventions, such as medications and psychotherapy, to alleviate the symptoms of ED.
Once you’ve been approved for the procedure, your doctor will provide the necessary documentation for Medicare coverage. Before you move forward with surgery, it’s important to make sure that the doctor and facility accept Medicare assignment.
Here’s how you can do that:
- If you have original Medicare, you can ask your doctor or surgeon whether they accept assignment.
- If you have Medicare Advantage, you can check your plan’s in-network provider list.
- If you have a stand-alone prescription drug plan, you can check your drug plan’s formulary ahead of time. A formulary is a list of medications covered by the plan.
Aside from penile implant surgery, there are many nonsurgical treatment options for ED, including:
- oral medications (such as sildenafil or avanafil)
- self-injectable medications (such as alprostadil and phentolamine)
- urethral suppository medications (such as alprostadil)
- testosterone replacement therapy
- penis pumps
Unfortunately, most of the nonsurgical treatment options for ED aren’t covered by Medicare. Most Medicare plans don’t cover oral or injectable medications like Viagra or ED equipment such as penis pumps.
Outside of penile implant surgery, the only major exception for ED treatment would be psychotherapy, which is included under Medicare Part B coverage.
It’s important to note that there are rare exceptions when some of these nonsurgical options might be covered.
For example, if the ED treatment is necessary in the treatment of another underlying health condition, then it might be covered. However, this is usually up to the discretion of your Medicare or Medicare Advantage plan.
If you receive treatment for ED that isn’t covered by your Medicare plan, you’ll owe 100 percent of those treatment costs out of pocket.
Out-of-pocket costs for Medicare may include:
What you can expect to pay for your penile implant surgery depends on:
- your plan
- the cost of the surgery
- whether you’ve already met your deductible
Part B costs
Medicare Part B costs include:
- a monthly premium of $148.50 or higher, depending on your income
- a yearly deductible of $203, which must be met before Medicare will pay for your medical services
- 20 percent coinsurance for the cost of the procedure
You can use Medicare’s cost lookup tool to see what your 20 percent might look like.
The costs shown above don’t include any Medicare Part D premiums, deductibles, or copayments for your prescription drugs during recovery.
Also, your Part B out-of-pocket costs may also be lower if you have a supplemental Medigap plan.
Part C costs
Medicare Part C costs include:
- the Medicare Part B monthly premium (listed above)
- a separate monthly premium and yearly deductible for your Part C plan
- copays and coinsurance for doctor’s visits, specialist’s visits, and prescription drugs
These costs are usually variable and depend on the type of Medicare Advantage plan you’re enrolled in.
Penile implant surgery, which utilizes a penile prosthetic, is used for the treatment of ED.
First, your doctor will decide whether you’re a good candidate for the procedure by reviewing your medical history and performing a full physical exam. You’ll be asked questions about the extent of your symptoms and whether you’ve tried other medications or treatment options for ED.
Generally, if you have a low sex drive, mental health issues, or reversible ED, your doctor may choose to address those issues first before approving a penile implant.
However, if there are other underlying conditions and your ED is chronic and unresponsive to other treatments, you’ll likely be approved for penile implant surgery.
During the procedure, a penile implant is inserted directly into the penis. This implant will either be an inflatable implant or a semirigid rod, depending on the type of implant chosen.
Each type of implant has various pros and cons, so you and your doctor will discuss which one is best for your needs. Once the implant is inserted into the penis, it can be manually controlled to produce an erection.
After the procedure, you’ll likely be given both antibiotics and pain medication to help control infection and reduce postoperative pain. It can take several weeks for the pain to subside, and it can take anywhere from 4 to 6 weeks until you can resume sex or other strenuous activities.
Penile implant surgery is an effective treatment for patients with ED. In a
Within a 5-year period after the surgery, patient satisfaction rates were roughly 83 percent. Not only was high sexual satisfaction reported, but many of these people also noted an overall improvement in quality of life.
Penile implant surgery is an effective treatment option for ED when traditional methods, such as medications or other devices, have been unsuccessful.
Medicare beneficiaries are covered under Medicare Part B or Part C for almost all services related to the procedure. However, prescription drug coverage is also needed to help cover any medications during the recovery period.
If you’ve been approved for penile implant surgery, confirm that your doctor and the surgical facility accept Medicare assignment.