Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

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 and his treating physician have requested authorization for daily Viagra. The Health Plan has denied this request stating that this quantity of medication is not medically necessary and instead has authorized six tablets per month. At issue is whether daily use of Viagra is medically necessary for treatment of the patients condition.The patient had a radical retropubic prostatectomy for prostate adenocarcinoma. The procedure was performed as a nerve sparing operation, specifically designed not to destroy those nerves running alongside the prostate that are needed for penile erectile function. This appears to have been successful, as return of erectile function was reported one year post-operatively. Since penile hypoxia may play a role in the development and progression of erectile dysfunction, attempts are made to minimize this problem during the time period when erectile dysfunction occurs post prostatectomy on a temporary basis due to transient but not permanent nerve damage arising from the surgery.The role of vacuum erection device in penile rehabilitation is not clear. While it may sometimes be effective in treating erectile dysfunction, it may also be detrimental in penile rehabilitation.PDE-5 inhibiting medications such as Viagra may be helpful in penile rehabilitation in that they can decrease penile hypoxia, even in the suberectile state. Thus, their use may be worthwhile in the time of transient post-operative erectile dysfunction, until the nerves have recovered from whatever temporary partial damage they may have sustained from surgery. There are studies that indicate daily use may help, though a recent large study has not shown that daily use is any more helpful than intermittent use on the occasion of anticipated sexual activity. In any event, this patient is now almost two years post-operative and has had some return of erectile function. There is no scientific evidence that daily use of such a medication is indicated for patients who are almost two years post surgery and have had some erectile function already re-established.In conclusion, a PDE-5 inhibiting medication is appropriate for use on an as needed basis for sexual activity and is not warranted on a daily basis. Therefore, I have determined the requested quantity of medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.