Tx For Impotence 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 49-year-old male who presented to his urologist in April 2003 with a one-year history of difficulty obtaining a full penile erection and of maintaining an erection, along with decreased libido. He was treated with Viagra and in August 2004 reported that it caused heartburn and was only effective half the time it was used. In October 2004 the patient underwent a urology consultation. The patient obtained a less than 50% erection with intracavernosal injection and this was reported to be about the same type of reaction that he achieves with Cialis. Sonography of the penile artery demonstrated a small right arterial inflow with crossover to the left and no distal flow past the crossed over site. The patient was diagnosed with erectile dysfunction most likely due to poor arterial inflow.

Where the denial was upheld

The patient is a 58-year-old male with prostate adenocarcinoma who underwent robotic assisted laparoscopic radical retropubic prostatectomy, nerve sparing, with bilateral lymphadenectomy in October 2004. His Gleason score was six, and there was one positive margin, but cancer follow-up through May 2006 revealed no evidence of recurrence of the prostate adenocarcinoma.In October 2004 treatment with Viagra was recommended for the purpose of potency rehabilitation. In November 2005 treatment with Viagra on a daily basis plus the use of a vacuum erection device was recommended for penile health. In May 2006 the patient was reported to be taking Viagra periodically, not daily, and not using a vacuum device. He was having erections that were satisfactory for sexual intercourse and improving (though partially diminished in rigidity).

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 Tx For Impotence, then check the rights and deadlines that apply to your plan.