Male Genital Dis: when insurers say no, reviewers often say yes

Where the denial was overturned

The parent of a 17-year-old male enrollee has requested surgery for treatment of the enrollee’s un-descended testicle. Findings: The physician reviewer found that the cause of cryptorchidism is multifactorial. An un-descended testis can be located anywhere between the abdominal cavity and just outside the anatomic scrotum. This patient’s medical records state that the testicle was by the external ring but could be linked to the upper scrotum. In the medical literature, Puri and Nixon described normal testicular descent as “a testis that remains stationary within the dependent portion of the scrotum”. Therefore, cryptorchidism is a developmental defect in which the testis fails to descend completely into the scrotum.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for 2,000 punch hair graft. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patient’s hair loss and are not reconstructive in nature. This patient has well-documented scar alopecia on the right side of the head, as a result of prior tissue transplant from the right temporal region of the scalp to relocate the tissue for penile reconstruction. This a complication of a medically necessary procedure. Therefore, reasonable intervention to correct this complication is medically necessary. However, the provider recommended a procedure for bilateral temple grafts (800 to 1,000 per side).

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostatic arterial embolization. Findings: The physician reviewer found that the patient is with over a decade year history of benign prostatic hyperplasia (BPH). He presented to his provider with symptoms of urgency, frequency, weak stream, difficulty voiding and nocturia. The patient has requested coverage for prostatic artery embolization to treat his BPH. The Health Plan has denied this request. Per the Health Plan, prostatic artery embolization is considered investigational for treatment of this patient. The medical literature does not show that prostatic artery embolization provides the same degree of improvement when compared to transurethral resection of the prostate or laser ablation of the prostate in patients with BPH.

Nature of Statutory Criteria/Case Summary: A 50-year-old male enrollee has requested authorization and coverage for Opana 45 mg daily. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. In this case, the patient was recently taking 270 MME per day. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for male genital dis was denied, the published record says the denial is worth fighting.