What follows is a pattern, not a patient — a composite of a conversation that comes up often enough in my practice that I can usually predict its shape before it starts.
A man has been living with erectile dysfunction for a decade or more. He has taken sildenafil, then tadalafil. There is a vacuum device somewhere in a closet. At some point a physician taught him injections, and he used them until they stopped working well enough to be worth the trouble. By the time he sits down to talk seriously about an implant, he has done essentially everything a urologist would ask a man to do first.
And almost none of it exists in writing.
That is not a small problem. It is frequently the problem — the thing standing between a man and the definitive treatment he has already earned the right to consider. So I built something to help fix it.
The Conversation I Have Almost Every Week
An inflatable penile prosthesis is the most reliably satisfying ED treatment we have, with satisfaction rates around 95% and hundreds of thousands of devices implanted worldwide. It is also surgery, and it is expensive, and insurers treat it accordingly.
Nearly every payer — Medicare, Medicare Advantage plans, commercial insurers, self-funded employer plans — expects to see that less invasive options were tried first. That expectation is reasonable. Implant surgery is irreversible; you don't start there. What surprises men is how specific the expectation is. It is generally not enough to say pills didn't work. The documentation is usually expected to show what was tried, at what dose, for how long, and what happened.
Most men can tell me that story out loud. Very few can produce it in a form a utilization reviewer will accept.
Requirements vary meaningfully by plan, but a documented trial typically means more than a single line in a chart note. It commonly means an adequate dose, taken correctly, tried multiple times, with a recorded outcome — and then the same for the next therapy. A man who tried sildenafil 50mg twice, four years ago, after dinner and a few drinks, has not completed a trial in the way most reviewers read the word. He may not have completed one in the clinical sense either. (See: Viagra vs. Cialis vs. Generic — What's Actually Different?)
Two Different Obstacles, Often Confused
When coverage for an implant is denied, it is worth understanding which wall you've hit, because the two look identical on a denial letter and require completely different responses.
The plan covers the procedure but isn't satisfied that you meet its criteria. This is the one documentation fixes. Better records, a clearer trial history, and a well-supported letter of medical necessity often turn these around.
The plan doesn't cover penile prosthetic surgery at all, for anyone, no matter how well documented. This is a contract problem, not a clinical one. Some commercial and self-funded plans carve prosthetics out entirely; some carve them back in for men whose ED followed cancer treatment. No amount of paperwork changes a benefit exclusion — but knowing early that you're facing one saves months.
This is why I tell patients to check their benefits before investing effort in a treatment ladder. Verification comes first; documentation comes second. Both come before a surgical date.
Why Memory Isn't Enough
Ask a man how a medication worked and you'll usually get an honest, useless answer: "not great." Ask what dose, how many times, whether he was aroused, whether he'd eaten, whether it was better or worse than the month before — and the answers evaporate. That's not a failure of character. Nobody keeps a log of their sex life on the off chance an insurance company will want it.
But the details are the whole case. And they matter clinically, not just administratively. A man who reports "the pills don't work" may in fact have never reached a maximum tolerated dose. A man discouraged by his first three injections may be two titration steps away from a result. Without a record, we're both guessing — and guessing usually leads to abandoning a therapy that hadn't actually failed yet.
"The details are the whole case — and they're the first thing lost. Nobody keeps a log of their sex life on the off chance an insurance company will want it."
What REPARO Does
REPARO is an iOS app I designed and built for exactly this gap. It is a patient-owned record of ED treatment — the thing I kept wishing my patients had walked in with.
Log the attempt, not the year.
Each time you use a therapy, you record it in a few taps: which treatment, what dose, how firm the erection was on a simple four-point hardness scale, and whether the attempt was satisfying. Oral medications, vacuum device sessions, and injections each have their own flow. The app nudges you toward a real trial — reminding you when you haven't yet reached a maximum dose, and only offering to mark a therapy as failed once you've actually given it a fair run.
Track the trend, not the moment.
Periodic check-ins using the SHIM (Sexual Health Inventory for Men), the same validated five-question instrument used in urology clinics, plotted over time. A single score is a snapshot; twelve weeks of scores is evidence. It also shows you something a snapshot can't — whether you're improving, holding, or sliding.
A library written by a urologist, not an algorithm.
Sixteen plain-language articles covering the treatment pathways, what to expect from each, injection technique and titration, penile rehabilitation after prostate cancer, and implant surgery itself. Readable without an account, because information shouldn't be behind a login.
See where you stand.
The app organizes your history against the kind of criteria payers commonly apply, so you can see which rungs of the ladder you've genuinely completed and which you haven't. Not a coverage determination — an honest picture of your own record before you walk into a consultation.
Privacy — Plainly
I'll be direct about this, because it's the question I'd ask first.
- Your entries are stored encrypted on your own device using AES-256 encryption, with the key held in the iPhone's secure hardware keychain.
- You can require Face ID to open the app, and lock it automatically after a period of inactivity.
- There is no advertising in REPARO, and your data is not sold or shared with drug manufacturers, device manufacturers, or anyone else.
I'm deliberately not making broader compliance claims while the app is in beta and under independent security review. What I can tell you concretely is the above — and that if you'd rather not put something in writing anywhere, don't. The app is useful even if you only log the therapies you're comfortable logging.
One related note: please don't email health details to me or to the waitlist address. Ordinary email isn't a secure channel for that, no matter who's on the other end.
What REPARO Is Not
It is not medical advice, and it does not replace your urologist. It cannot prescribe, adjust doses, or tell you a therapy has failed.
It is not a guarantee of insurance approval. Coverage depends on your specific plan's terms, your medical history, and your physician's documentation. A well-kept record strengthens a case; it doesn't decide one.
And it is not a substitute for your medical chart. Bring what you've logged to your appointments — the point is to make the clinical record better, not to replace it.
How to Get It
REPARO is in invitation-only beta on iOS through Apple's TestFlight program while we finish testing and independent security review. There's no cost to join.
To be notified when access opens, add your email to the waitlist at reparomenshealth.com. Email address only — no health information.
Documenting Your Options Is the First Step
Whether you're at the beginning of the treatment ladder or you've been on it for a decade, a consultation can clarify where you actually stand — clinically and with your benefits.
Request a Consultation (504) 584-6990 Join the REPARO Waitlist →Men in this position usually do get where they're going. But "eventually" can mean appeals, delays, and the painstaking reconstruction of a history that was lived through and never written down — a history that could have been captured a few seconds at a time, years earlier.
Nobody should have to spend months proving something they have already done.