First: what kind of 'no' is this?
| Type | What it means | Worth appealing? |
|---|---|---|
| Benefit exclusion | The plan does not cover drugs for erectile dysfunction at all. Common, and Medicare Part D generally excludes them. | Rarely. Focus on cash price instead — see cost and insurance. |
| Prior authorisation required | Covered in principle, but paperwork is missing. | Yes — this is usually just an administrative fix. |
| Not medically necessary | The plan disputes the clinical justification. | Yes. This is the appeal most often overturned. |
| Step therapy | You must fail cheaper options first. | Yes, if you have already failed them and it was not documented. |
| Quantity limit | Covered, but fewer doses than prescribed. | Sometimes, with clinical justification. |
| Out of network | The provider is not contracted. | Sometimes, if no in-network specialist is available. |
Building the case
Medical-necessity appeals are won on documentation, not on argument. The reviewer is looking for specific things.
- The underlying diagnosis and its cause — post-prostatectomy, diabetic neuropathy, Peyronie's disease and spinal injury all carry more weight than unexplained ED.
- Documented failure of conservative treatment: which medications, what doses, how many attempts, what happened. This is the element most often missing.
- Contraindications to cheaper options — nitrate use, for example, rules out the entire PDE5 class and is a strong argument.
- Functional impact, described concretely rather than vaguely.
- Clinical guideline citations. Your clinician can reference the AUA erectile dysfunction guideline directly.
- A letter of medical necessity from the treating clinician, addressing the plan's stated reason for denial point by point.
The process
- Get the denial in writing, with the specific reason and the plan language it relies on. Ask for it if it did not arrive.
- Request the clinical criteria the plan used. You are generally entitled to these, and they tell you exactly what the appeal must demonstrate.
- File the internal appeal within the deadline stated in the letter — deadlines are strict and missing one usually ends it.
- Ask your clinician for a peer-to-peer review. A direct conversation between your clinician and the plan's medical reviewer resolves a meaningful share of denials without a formal appeal.
- Request an expedited appeal if delay would cause harm; timeframes are much shorter.
- Escalate to external review if the internal appeal fails. An independent reviewer outside the plan makes a binding decision, and this is where a substantial number of denials are overturned.
- Complain to your state insurance regulator if the process itself is being handled improperly.
While the appeal runs
- Price the generic as a cash purchase — for tablets this frequently costs less than the effort of the appeal. See cost and insurance.
- Check manufacturer patient assistance programmes for brand-name products.
- Use HSA or FSA funds, which generally cover prescription ED medication.
- Ask whether a different agent in the same class is on formulary.
- For devices, ask the manufacturer about direct-purchase pricing — sometimes lower than the insured route.
FAQ
Frequently asked questions
Does insurance cover ED medication?
Frequently not. Many plans exclude the category outright, and Medicare Part D generally excludes drugs used for erectile dysfunction. Plans that do cover them often impose quantity limits.
Is a penile implant covered?
Often yes, when documented as medically necessary after conservative treatment has failed — a striking contrast with the tablets. Get the prior-authorisation criteria in writing.
How many appeals do I get?
Typically an internal appeal with your plan, followed by an independent external review. Both have deadlines stated in the denial letter.
What is a peer-to-peer review?
A direct conversation between your clinician and the plan's medical reviewer. It resolves a meaningful share of denials quickly and is worth requesting early.
Sources
What this is based on
We link to primary sources — clinical guidelines, regulator publications and peer-reviewed research — wherever possible. Links open on third-party sites we do not control.
- [01]American Urological Association. Erectile Dysfunction: AUA Guideline (2018).
- [02]Urology Care Foundation. What is Erectile Dysfunction?.
- [03]National Institute of Diabetes and Digestive and Kidney Diseases. Treatment for Erectile Dysfunction.