Erectile Dysfunct Rx denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has a history of BPH (benign prostatic hyperplasia). The patient’s symptoms include urinary hesitancy and nocturia. The patient has been treated with Flomax but found that it was bothersome to his premature ejaculation. His premature ejaculation has been a lifelong problem. The patient has also been treated with Rapaflo but stopped using it due to the cost; the medication was noted to improve his symptoms. The provider recommended Tadalafil tablet 5 mg. The Health Plan indicates that the requested medication is not medically necessary for the treatment of the patient’s medical condition. At issue in this case is whether Tadalafil tablet 5 mg is medically necessary for the treatment of this patient.

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: The parent of an enrollee has requested authorization and coverage for sildenafil. One study demonstrated no favorable significance of sildenafil in improving maximal oxygen consumption in patients with Fontan circulation. Although the patient has a condition where elevated pulmonary vascular pressures and resistance are detrimental, there is a lack of a recent diagnostic study for this patient which has demonstrated pulmonary hypertension. In fact, the most recent cardiac catheterization demonstrated normal pulmonary artery pressures. Moreover, the patient is asymptomatic per the provider’s records with normal oxygen saturation on room air.

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