Benign Prostatic Hyperplasia denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee requests authorization and coverage for the UroLift procedure. According to the enrollee’s medical record, the enrollee is diagnosed with benign prostatic hyperplasia (BPH) with severe obstructive symptoms. He was told 20 years ago that he has a congenital deformity of the median lobe. He has urinary frequency, nocturia, and incontinence. He received treatment from multiple urologists and tried four medications (Proscar, Avodart, Flomax, and Cardura). He had not pursued surgery before because he was concerned for retrograde ejaculation; however, his symptoms have worsened. The enrollee states that because of his age and history of sleep apnea, he cannot tolerate the general anesthesia required for a transurethral resection of the prostate (TURP) procedure.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Rezum transurethral destruction of prostate tissue (CPT/HCPCS codes 53854, 96372, and J1885). This patient presented with a diagnosis of benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. He has failed conservative treatment with medical BPH management. He underwent further work-up, which revealed a prostate size less than 80 grams and presence of a median lobe. BPH is non-cancerous enlargement of the prostate which often causes urinary obstruction leading to lower urinary tract symptoms of weak stream, frequency and nocturia. Treatment begins with medical management including alpha blockers, 5-alpha reductase inhibitors, or a phosphodiesterase inhibitor.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting reimbursement and authorization and coverage for the daily use of Cialis (Tadalafil). The enrollee has prostate pain, initially seen with complaints of bladder pressure, constipation, fatigue, nocturia, sexual dysfunction, urinary frequency and urinary urgency. Cialis was prescribed. A follow up visit indicated symptoms had improved with Kegel exercises. The enrollee did not want to take Finasteride or similar medications due to risk of impotence on the side effects list. He was experiencing sexual dysfunction, urinary dribbling and urinary frequency. Review of the enrollee’s active medications in the record shows the provider prescribed Finasteride tablet. The provider’s assessment/plan on a follow up visit indicates the enrollee requested Cialis.

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 benign prostatic hyperplasia, then check the rights and deadlines that apply to your plan.