Organic Erectile Dysfunction and the Insurance Industry

I know that many patients have been associated with insurance companies that have not accepted to pay for various procedures and treatments. Some have a blanket policy concerning the diagnosis and treatment of erectile dysfunction.

Insurance companies that had previously paid for the diagnosis and treatment of organic sexual disease, whether by medical or surgical means, are no longer paying for patients who need treatment for their sexual difficulties, invoking a provision that excludes the treatment of sexual dysfunction.

Some insurance companies, who for example are limiting ViagraTM treatment, also are prohibiting more extensive diagnostic evaluations, as well as more aggressive treatments for those patients who suboptimally or do not respond to Viagra at all.

I recently treated a patient, a retired government employee. I preformed a radical prostatectomy for cancer of the prostate. He is likely cured of his prostate cancer with a procedure that was fully covered by his insurance. Yet the erectile dysfunction that partially resulted from that surgery is not covered. His erectile dysfunction has effected his lifestyle. So after great trepidation he decided to have a penile implant since no other minimally invasive therapy works on him.

The patient was properly counseled, surgery was scheduled, and, low and behold, the insurance carrier denied the surgery on the basis of its sexual dysfunction exclusion provision. The patient was flabbergasted. Here he had a major surgery for cancer of the prostate paid for by the insurance company. Yet now, they insurance will not pay to deal with the life-altering functional disorder produced by his curative surgery.

The insurance company held strong, the patient complained and wrote to various government and insurance executives, but to no avail. The patient decided to spend $12,000.00 out of his own pocket to have this surgery. Afterwards, the patient said to me it was worth every dollar, and it has improved the image of himself and his relationship with his wife, important psychological and social aspects of a person's life.

It's certainly possible some insurance companies would have covered this case. And that's good. The point is all should.

Having told this story let's look at what we can do to resolve the problem. The first thing is for the insured to check if there are exclusions for sexual dysfunction. Next, the term sexual dysfunction needs to be broadened. It is an all encompassing term. It doesn't just include erectile dysfunction, but also includes anorgasmia, poor sexual desire, and premature ejaculation. There are probably 75 million men with all these problems, and only 30 million men with erectile dysfunction.

Most of these men have organic disease; diseases which the insurance company will pay to diagnose and treat. Diabetes, hypertension, heart disease, vascular problems, multiple sclerosis, and spinal cord injuries will certainly be treated by their insurance company and all the problems related to such as well, but not erectile dysfunction. The insurance companies must realize that sexual dysfunction is not erectile dysfunction, and that most erectile dysfunction is not psychological. It is mostly physical and caused by diseases that normally would be paid for by them. The erectile dysfunction is the result of their disease or the treatment of their disease and should be paid for.

On the other hand, many patients have insurance contracts that allow for the plastic surgical repair of functional disorders, and those patients who don't respond to less invasive therapies should certainly consider using the plastic surgical provision which allows for the payment of a functional disorder. Isn't sexual dysfunction after cancer surgery a functional disorder? Severe vascular disease, hypertension, diabetes that leaves the patient incapable of performing sexually, many of whom do not respond to Viagra or Muse or intracavernosal injection, should certainly be allowed to have their surgery on the basis of this plastic surgical functional provision.

All diagnostic and treatment modalities should be covered by the patients insurance including the cost of Viagra, Muse, injection therapy, and penile implants.

This is not to say that other sexual dysfunctions which equally as debilitating, physically and psychologically, should also not be considered for evaluation and treatment as well. The psychosocial aspects of erectile dysfunction and other sexual dysfunction are so debilitating, costly, and nonproductive that the insurance companies should realize that the treatment of these would be beneficial to their overall cost structure and public relations.

It's an issue whose time has come. In this editorial I haven't discussed other insurance issues, such as paying for birth control pills, or what will be advances in treatment for women with sexual dysfunction. But there is an opportunity now for a break though. I hope the insurance companies realize that.