Peyronie's Disease 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Trental and verapamil for treatment of the enrollee’s Peyronie’s disease. Findings: The physician reviewer found that There is a lack of strong evidence based literature to support the medical necessity of the medications at issue in this clinical setting. The use of verapamil injections has been studied for management of patients who are diagnosed with Peyronie’s disease (PD). However, the literature recommends that further studies need to be conducted to determine its efficacy for the treatment of PD and the associated symptoms with this disease.

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement and prospective authorization and coverage for enhanced external counterpulsation (EECP) for treatment of the enrollee who has been diagnosed with Peyronie’s disease. Findings: The physician reviewer found that There are limited trials that note the efficacy of the services at issue. Additionally, the medical literature does not indicate if EECP therapy is safe and effective in decreasing the pain and curvature that are associated with Peyronie’s disease. His degree of curvature is not documented and the outcome of the therapy have not been documented. EECP is not accepted as a standard of care for the management of Peyronie’s disease. In recent trials, certain novel therapies have shown to be superior to EECP. Moreover, this patient does not have any trouble with intercourse.

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 peyronie's disease, then check the rights and deadlines that apply to your plan.