Erectile Dysfunction denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient is a 54-year-old male who was diagnosed with erectile dysfunction and Peyronie's disease. The patient had an episode of ischemic priapism, which was likely secondary to medication management of his bipolar disorder. The patient was treated with an operative shunt. Since the time of shunt placement, intracavernosal injections and vacuum erection devices have failed to provide adequate penile tumescence for penetration. The patient has requested coverage for a penile prosthesis. The Health Plan denied the request and reported that the requested device is not medically necessary for the treatment of this patient. At issue in this case is whether a penile prosthesis is medically necessary for the treatment of the patient’s medical condition.

The patient is a 57-year-old male with the diagnosis of Peyronie’s disease. This has reportedly been present for eighteen months and has been associated with erectile dysfunction. In his report from October 2005, the urologist described the patient’s symptoms as reduced (penile) rigidity along with some penile shortening but no significant curvature. The patient is reported as still being able to achieve vaginal penetration and his libido is described as healthy. Physical examination at that time revealed fairly diffuse Peyronie’s plaque on the dorsal and lateral aspect of the mid penis.The patient’s urologist recommended transdermal Verapamil gel in order to avoid surgery.

Where the denial was upheld

The patient is a 58-year-old male with prostate adenocarcinoma who underwent robotic assisted laparoscopic radical retropubic prostatectomy, nerve sparing, with bilateral lymphadenectomy in October 2004. His Gleason score was six, and there was one positive margin, but cancer follow-up through May 2006 revealed no evidence of recurrence of the prostate adenocarcinoma.In October 2004 treatment with Viagra was recommended for the purpose of potency rehabilitation. In November 2005 treatment with Viagra on a daily basis plus the use of a vacuum erection device was recommended for penile health. In May 2006 the patient was reported to be taking Viagra periodically, not daily, and not using a vacuum device. He was having erections that were satisfactory for sexual intercourse and improving (though partially diminished in rigidity).

The patient is a 58-year-old male with organic erectile dysfunction on a vascular basis due to arteriosclerosis, diabetes mellitus and hypercholesterolemia. According to the December 2005 urology report, he is taking Nitrostat, a nitroglycerin preparation. The patient’s previous treatment with Viagra, an oral PDE-5 inhibiting medication, was unsuccessful as was treatment with Caverject intra-cavernosal injection therapy. Surgical treatment with the placement of a multi-component penile prosthesis has been recommended by his urologist. The Health Plan denied authorization for this procedure based upon a determination that it is not medically necessary.The medical records presented indicate that this patient has erectile dysfunction on an organic basis, due to diabetes mellitus and vascular disease.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving erectile dysfunction, then check the rights and deadlines that apply to your plan.