Cialis denials in California external review

What the reviewers wrote

Where the denial was overturned

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.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a dosing regimen for the medication, Cialis. Findings: The U.S. Food and Drug Administration (FDA) approves the use of Cialis (generic name tadalafil) for the treatment of erectile dysfunction (ED). A study notes that in a randomized, double-blind study of patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH), treatment satisfaction was greater with tadalafil over placebo. The authors further found that in patients with LUTS from BPH, tadalafil improved flow rates by 2.4 mL per second, compared with an improvement of around 2.2 mL per second with alpha blockers such as tamsulosin.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting reimbursement and authorization and coverage for the daily use of Cialis (Tadalafil). The enrollee has prostate pain, initially seen with complaints of bladder pressure, constipation, fatigue, nocturia, sexual dysfunction, urinary frequency and urinary urgency. Cialis was prescribed. A follow up visit indicated symptoms had improved with Kegel exercises. The enrollee did not want to take Finasteride or similar medications due to risk of impotence on the side effects list. He was experiencing sexual dysfunction, urinary dribbling and urinary frequency. Review of the enrollee’s active medications in the record shows the provider prescribed Finasteride tablet. The provider’s assessment/plan on a follow up visit indicates the enrollee requested Cialis.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cialis 5 mg daily, #30 per 30 days for treatment of the enrollee, who has been diagnosed with benign prostatic hyperplasia and erectile dysfunction. Findings: The physician reviewer found that Phosphodiesterase-5 (PDE-5) inhibitors like Cialis have been studied in men with benign prostatic hyperplasia/lower urinary tract symptoms. The efficacy of Cialis for benign prostatic hyperplasia/lower urinary tract symptoms is based on findings that show the expression of the PDE-5 enzyme in the lower urinary tract (prostate, bladder, urethra and vascularity). PDE-5 inhibition results in smooth muscle relaxation and may increase pelvic blood perfusion, which is suspected to affect smooth muscle tone.

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 Cialis, then check the rights and deadlines that apply to your plan.