CAPU targets Congress to improve prostheses funding

October 1, 2006

Washington-Members of the Coalition for the Advancement of Prosthetic Urology (CAPU) spent several days during the last week of September pounding the halls on Capitol Hill, lobbying Congress to improve payment for prosthetic urology procedures and seeking comprehensive insurance coverage for prosthetic urologic procedures. Now they wait to see what their efforts may have won.

"We chose to go to the Hill immediately following Prostate Cancer Awareness Week [Sept. 18-23]," said John J. Mulcahy, MD, PhD, chairman of the 4-year-old organization and one of its founders.

The idea was to catch lawmakers while urologic health issues were still on their minds, he told Urology Times.

"We are looking to achieve the same type of coverage for prostate cancer survivors that Congress mandated for breast cancer survivors. Current legislation allows payments for breast reconstruction following mastectomy, but there is no such support or reimbursement for male rehabilitative procedures, such as penile prosthesis after radical prostatectomy."

The primary goal of the continuing lobbying effort is to maintain and improve Medicare payment for male prosthetic procedures. In the past, CAPU successfully fought off attempts to reduce payments. It stopped an effort last year by one congressional committee to eliminate all funding for penile prosthetics and procedures.

Dr. Mulcahy noted that this was a significant accomplishment under last year's circumstances. The 2005 lobbying effort fell during the week after Hurricane Katrina hit, when lawmakers were still pondering the estimated billions of dollars that reconstruction would cost.

This year, CAPU is seeking funding increases for a number of procedures to include insertion of urethral bladder neck sphincter (CPT 53445), insertion of multi-component penile prosthesis (CPT 54405), removal and/or replacement of penile prosthesis (CPT 54410), and removal and complete replacement of penile prosthesis (CPT 54411).

One of the myths the apprentice lobbyists hope to dispel is that prosthetic procedures are performed solely to enhance sexual function. Dr. Mulcahy said that one of the accomplishments of earlier lobbying efforts was convincing legislators that prosthetic procedures were directed at restoring natural function lost as a result of disease and subsequent therapeutic intervention.

CAPU members also handed legislators and their aides a five-page piece of model legislation that would require private insurers to cover the costs of penile prosthetic procedures.

Equal coverage sought

"Medicare covers the procedures, and most federal health plans cover it, but private insurers, such as Blue Cross, Blue Shield, and others, do not cover it, especially for men under age 65. They view the procedures as sexual enhancement procedures. It is a terrible situation," explained Gail Daubert, CAPU's primary lobbyist.

"A few years ago, Congress passed legislation for women that required that all insurers who cover mastectomy also cover the costs of reconstructive surgeries. At first, legislators thought of breast reconstruction as cosmetic, but the women lobbied and convinced them that reconstruction was part of the healing process.

"We have modeled the Post-Prostate Cancer Treatment Equity Act legislation on the same format as the breast reconstruction legislation (the Women's Health and Cancer Rights Act of 1998), in which Congress recognized that breast reconstruction surgery is an important component of a woman's total breast cancer treatment and recovery," Daubert said.

"Just as the Women's Health and Cancer Rights Act requires private health insurers to cover breast reconstruction following mastectomies if the insurer covers treatment for breast cancer, the Post-Prostate Cancer Treatment Equity Act tells insurers who cover prostate cancer treatment, which all of them do, to also cover the costs of reconstructive surgery in those men who need it."