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

Where the denial was overturned

Findings: The physician reviewer found that the patient has requested authorization and coverage for Xyosted. The American Urological Association guidelines for the evaluation and management of testosterone deficiency set forth criteria for testosterone replacement therapy. The criteria requires two documented testosterone levels less than 300 ng/dL, as well as symptoms of low testosterone. In this case, the patient has a history of hypogonadism manifesting as low testosterone. The records indicate that the patient has had two laboratory results showing total testosterone of 293 ng/dL and 189 ng/dL, both of which are below the 300 ng/dL threshold prescribed by the American Urological Association guidelines. The records also show that the patient has symptoms of low libido, erectile dysfunction, and sleep disturbances, which are symptoms listed in the guidelines.

Nature of Statutory Criteria/Case Summary: The patient requested reimbursement and prospective authorization and coverage for clomiphene citrate.The American Urological Association (AUA) Guidelines on the Evaluation and Management of Testosterone Deficiency, specifically Guideline Statement 27, explains that clomiphene citrate is widely accepted as a treatment for low testosterone in males. The AUA guidelines specifically list clomiphene citrate as one of the appropriate alternative therapies commonly used to promote the endogenous production of testosterone. It further supports the use of clomiphene based on studies that showed that clomiphene citrate has outstanding biochemical and clinical efficacy, with increases in serum testosterone similar to those for testosterone gel.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the scrotum and/or surgical intervention to remove the mass on the enrollee’s testicle. The American College of Radiology (ACR) state that ultrasound of the scrotum with Doppler should be the first study in the evaluation for scrotal mass and/or pain in all scenarios. Given the superficial location of the testicles and epididymis relative to the skin and short depth of these organs, ultrasound has excellent sensitivity in detecting lesions. MRI is not considered a primary method for evaluation of the scrotum. Rather, the available literature indicates an adjunct role for MRI in further differentiating and characterizing lesions found by ultrasound.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for platelet rich plasma injections. The guidelines on the use of biologics, including platelet rich plasma, for lumbar facet arthropathy note that at present, there is very little literature regarding the application of stem cells in the treatment of facet joint and sacroiliac joint pain. The further notes that a methodologic quality assessment of lumbar facet intraarticular injections reported that due to the limitations of three studies, a meta-analysis could not be performed.

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 disorder was denied, the published record says the denial is worth fighting.