(218) Emerging Data Regarding Disparities in Insurance Coverage of Male Sexual Health Conditions

Abstract

Abstract Introduction Medical policy bulletins (also known as clinical policy bulletins) are insurance company guidelines for administering plan benefits. These documents purport to summarize current research, evidence-based guidelines, regulatory status, and physician opinion to determine whether insurers consider procedures and services to be medically necessary. These bulletins, along with member benefit plans, determine which services are covered. We have previously explored the lack of uniformity that exists for insurance payer coverage for penile prostheses. Here, we sought to expand this investigation to determine insurance coverage criteria for medical and surgical management of common men’s health conditions. Objective To determine covered benefits for sexual medicine conditions among the top United States healthcare insurers. Methods A list of common sexual medicine conditions was generated, including Peyronie’s disease, hypogonadism, erectile dysfunction, premature ejaculation, incontinence, and buried penis. The most common treatment modalities for each condition were identified (see Table I). Securities and Exchange Commission (SEC) filings were used to identify the top ten largest private insurers in the United States by member enrollment. This list was cross-referenced with the National Association of Insurance Commissioners (NAIC) 2020 Market Share Report (ref 1). The following list of the largest private US health insurers was thus developed: United, Anthem, Centene, Kaiser, Humana, CVS, Healthcare Service Corporation (HCSC), Cigna, Molina, and Independence Health Group (IBX). Kaiser and Centene were excluded due to lack of nationwide medical policy bulletins. We reviewed medical policy bulletins from the remaining 8 insurers to determine whether the specific treatments were identified as medically necessary, experimental/investigational, or cosmetic. Services and procedures deemed medically necessary were coded as “covered,” and those listed as investigational, or cosmetic were coded as “not covered.” If information about a specific condition or treatment modality was not found in a company’s policy bulletin, it was coded as “unknown.” Results In total, we recorded 143 data points, across the 8 insurance providers. Our review of medical policy bulletins yielded 60 (41.9%) instances where services were considered medically necessary and/or “covered”, 18 (12.6%) non-covered or investigational/cosmetic services, and 65 (45.5%) services with unknown coverage (Table I; covered=1, non-covered=0, unknown=2). Conclusions We encountered substantial difficulty in navigating and interpreting insurance coverage for various sexual medicine treatments and conditions based on review of policy bulletins from the topic insurance providers in the US. There was no readily identifiable coverage information for >45% of the data points that we collected, and instances of “unknown” coverage exceeded covered services across the collective of the largest private insurers. While 76.9% of conditions for which there was available data were covered, we are unable to draw generalizable conclusions for most conditions as there are significant deficits in the availability of policy information from online insurance sources. Further challenges in determining coverage include the additional layers of limitations in member plan benefits (i.e. plan exclusions), which could compound confusion for both physicians and patients. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast.