A Veteran contacted our Office after exhausting all review and appeal options when his request for low-dose daily medication to treat Erectile Dysfunction was denied by VAC. The on-demand higher-dose alternatives that VAC approves as a standard benefit had previously caused side effects for the Veteran.
Medical records supporting the daily low-dose prescription had been submitted with a disability benefit claim but were not available to staff reviewing the medication coverage request due to privacy and confidentiality safeguards that restrict access to VAC systems.
We found the outcome unfair because neither the Veteran nor their health care provider was informed of the VAC guidelines used to assess the request, and Veterans are not generally advised that records submitted in support of one VAC program may not be accessible to staff making decisions under another program. As a result, the Veteran did not have a full opportunity to provide information addressing the applicable VAC guidelines or to ensure that relevant medical evidence already on file was considered.
With the Veteran’s consent, our Office provided the medical information from the Veteran’s VAC file, and applicable VAC guidelines, to Medavie Blue Cross for a new decision.
Result
The Veteran was approved for coverage of the low-dose daily medication on an ongoing basis, and eligible past medication expenses were reimbursed.