Viagra denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 56-year-old male with multiple problems who is requesting Viagra to treat erectile dysfunction. The patient’s medical diagnoses include non-Hodgkin’s lymphoma (in remission), ulcerative colitis (in remission), primary sclerosing cholangitis with liver damage, multiple sclerosis, and depression.At the time of his hepatology consultation in May 2006 he was taking Vicodin as needed for kidney stone pain, Cipro for ascending cholangitis, and Protonix for GERD symptoms. It has also been recommended he be started on Provigil.

The patient is a 55-year-old male with erectile dysfunction. Upon examination the patient was overweight with a height of 5’6” and weight of 179 pounds. Blood tests included normal PSA, glucose and testosterone, but lipids were not measured. His treating physician noted that the patient had benefited from a trial of Viagra and therefore authorization for the medication was requested from the Health Plan. The Health Plan denied this request on the basis that Viagra is not medically necessary for treatment of the patient’s condition.Review of the submitted clinical evidence indicates the cause of the patient’s erectile dysfunction has not been fully determined. The patient is overweight and may have a problem with lipid metabolism. He may also have peripheral vascular disease, either arterial on the basis of abnormal lipids or venous due to a leak from the corpora cavernosa of the penis.

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).

The patient is a 60-year-old female with pulmonary hypertension. Her physician has stated her pulmonary pressures are elevated. She is taking multiple medications for management of her medical condition. In addition, her physician has recommended the addition of Viagra to the patient’s medication regimen for treatment of her pulmonary hypertension.The patient is a 60-year-old female with pulmonary hypertension. According to a hospital summary dated 7/15/04, the patient has multiple medical problems including pulmonary hypertension, systemic lupus erythematosus (SLE), congestive heart failure, hyperlipidemia, diabetes mellitus, and status post DVT/PE.

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