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SCOTTSDALE, Ariz. -- At least 21 states still don't provide Medicaid coverage for penile implants in patients with erectile dysfunction (ED), a new study found.

In contrast, 49 states cover male urethral slings, and 48 states cover insertion of artificial urinary sphincters for male incontinence, reported John Barnard, MD, of West Virginia University in Morgantown, who presented the findings at the annual scientific meeting of the Sexual Medicine Society of North America.

"My interpretation is that urinary leakage is viewed by the general populace as more of a true pathology, while erectile function is viewed as more of a luxury," he noted.

Of the 21 states that do not cover penile implants via Medicaid, several are large states with Republican-dominated legislatures such as Texas, Georgia, Florida, Arizona, and Missouri. But "there was not a strict correlation based on red/blue," Barnard said. "For instance, many of Appalachia and some Midwestern states have coverage, as well as some of the more traditionally blue states. I think the bigger issue is a cultural belief or bias that restoration of erectile function is a luxury or non-medically necessary or cosmetic treatment in some way."

Laurence Levine, MD, of Rush University in Chicago, told MedPage Today that more states should cover the implants. "Men who get an IPP [inflatable penis prosthesis] for severe ED are the happiest campers in my practice because they get something that readily restores their ability to have sex again without changing their sensation, orgasm, ejaculation, and urination. The self-esteem factor goes through the roof."

An estimated tens of thousands of penis implant (prosthesis) surgeries are performed in the U.S. each year, often in men whose ED isn't effectively treated with medications like sildenafil (Viagra). Many implants are inflatable via a pump that's implanted in the scrotum. The pump allows liquid to flow into the implant cylinder and create an erection.

Barnard and colleagues conducted their study after they noted that physician fee schedules in California offered conflicting details about coverage for penile implants. "Commonly held belief is that penile implant surgery is not covered under Medicaid," Barnard told MedPage Today. "We performed a state-by-state review to see which states included a value for physician reimbursement for penile implant surgery, and if so, did they specifically state prior authorization requirements?"

Other insurers -- including private insurers, Medicare, and the VA -- generally offer full coverage of sexual medicine treatments, although they often require prior authorization, he added. "Some treatments which are emerging or experimental are currently not covered, and further data supporting efficacy will be required before a decision is made for including these in the fee schedules," Barnard said. "For example, shockwave therapy for ED, platelet rich plasma, and stem cell therapies for ED are currently fully out-of-pocket for patients."

For the penile implant study, which was also published in the , the researchers examined state Medicaid physician fee schedules. Twenty-eight states covered at least one type of penis implant: Alaska, Arkansas (only the malleable type), California (only the malleable type), Colorado, Connecticut, Hawaii, Illinois, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Hampshire (only the implantable type), New Jersey, New York, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota (only a self-contained implantable device), Vermont, Virginia, and Washington.

The average physician reimbursement was $477 for malleable implants and $692 for inflatable implants, which is lower than the average Medicare rates of $541 and $823, respectively.

At the request of MedPage Today, Barnard checked Washington D.C., and found data that suggested it covers both kinds of penis implants.

Information was not available for one state. According to Barnard, Tennessee has a complicated Medicaid system without a publicly available physician fee schedule. "I reached out to them," he said, "and they requested I submit a specific patient claim and would not give me any details regarding coverage."

Ranjith Ramasamy, MD, of the University of Miami Health System in Florida, who wasn't involved with the study, told MedPage Today that his team's own research has that about "approximately half of our commercially insured patients are denied coverage for IPP regardless of etiology of ED. The most alarming trend is that men with ED after prostatectomy for prostate cancer are among those who are denied coverage for IPP; these men undergo surgery for cancer control but are unable to acquire therapy to treat a common side effect of that surgery."

Ramasamy, who praised the new research, added that American Urological Association guidelines no longer require men to fail medical therapy for ED in order to qualify for IPP. "Any man on Viagra can convert to IPP if they so desire," he said. "Thanks to advances in IPP technology and surgical techniques, patient satisfaction after IPP has been reported to be higher than that of patients treated with oral or intracavernosal meds."