Tx for Impotence denials: 60.0% overturned by independent reviewers
In 75 California IMR decisions from 2002 to 2018, reviewers overturned the plan 45 times (60.0%). Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| GU/ Kidney Disorder | 68 | 64.7% | — |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 19 | 21.1% | 60.0% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 10 | 90.0% | 60.0% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 9 | 11.1% | 60.0% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 6 | 100.0% | 60.0% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 6 | 50.0% | 60.0% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cialis for treatment of the enrollee’s erectile dysfunction. Findings: The physician reviewer found there is support in the medical literature as well as in the documentation provided for the requested medication in this clinical setting. The patient has erectile dysfunction. Phosphodiesterase inhibitors including Cialis are considered standard …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested Cialis 20 mg for treatment of his erectile dysfunction. Findings: The physician reviewer found that erectile dysfunction is a common medical condition in men over 50 years of age, with aging being the most common etiology for vascular disease leading to erectile dysfunction. Phosphodiesterase type 5 (PDE5) inhibitors are first line …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cialis 5 mg for treatment of his enlarged prostate with lower urinary tract symptoms. Findings: The physician reviewer found that the records provided for review document that this patient’s irritative lower urinary tract symptoms and erectile dysfunction were improved substantially with Cialis. His urinary tract symptoms have …”
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
How often were Tx for Impotence denials overturned?
In 75 California IMR decisions from 2002 to 2018, reviewers overturned the plan 45 times (60.0%).
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.