Levitra denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 66-year-old male who is requesting authorization for Levitra (5 phosphodiesterase inhibitor) for the treatment of erectile dysfunction. The Health Plan has denied this request on the basis that the patient has no clear etiology for erectile dysfunction and therefore, the patient does not have an established diagnosis required for authorization of Levitra.The patient’s records document the patient has hypertension, elevated cholesterol and that he underwent transurethral resection of the prostate in 1999. The patient dates the onset of his erectile dysfunction to the prostate procedure. The patient initially had some success with Viagra but indicates that it is no longer effective. He is now seeking authorization for Levitra.Viagra and Levitra are accepted primary therapy for erectile dysfunction. Treatment of erectile dysfunction is goal directed.

The patient is a 51-year-old male who is requesting authorization and coverage for the medication Levitra for treatment of erectile dysfunction. His history is positive for HIV, anxiety and insomnia and he is being treated medically for these conditions. The Health Plan has denied the patient’s request for Levitra on the basis it is not medically necessary.Treatment of erectile dysfunction is goal directed. Treatment that is successful and acceptable to the patient and his partner is appropriate therapy. The 5-phosphodiesterase inhibitors such as Viagra and Levitra are accepted primary therapy for erectile dysfunction. These medications are effective for approximately 70% of patients who have no contraindications or side effects. Based upon the information provided, it does not appear the patient has been tried on Levitra.

Where the denial was upheld

A 52-year-old male enrollee requested reimbursement and prospective authorization and coverage for Levitra provided from a specific date and forward. Findings: The physician reviewer found that the patient’s medical history includes difficulty with erectile dysfunction (ED) with specific complaint of difficulty with erection. This symptom is consistent with the diagnosis of ED but the origin of the condition was not identified. The evaluation that was included for review did not lead to a specific cause of his symptoms. The medication that he is requesting may improve this symptom, but does not treat the cause of the problem. Although the origin of the symptom is not always identified in a completed work-up, overall, the submitted clinical documentation does not meet the requirements as defined by the American Medical Association (AMA) to consider Levitra medically necessary.

The patient is a 41-year-old man who has requested authorization for Levitra or Viagra for treatment of erectile dysfunction. The Health Plan has denied the patient’s request indicating that he has no clear etiology for the erectile dysfunction. Additionally, the Health Plan indicates treatment for erectile dysfunction as a result of psychogenic impotence is not medically necessary.Viagra and Levitra are accepted primary therapy for erectile dysfunction. Treatment of erectile dysfunction is goal directed. Treatment that is successful and acceptable to the patient and his partner is appropriate therapy. In the case of this patient, the submitted information does not document an adequate history or evaluation to establish a diagnosis of erectile dysfunction.

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