Incontinence denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 45-year-old female with a 20-year history of urinary urge incontinence and a more recent history of stress incontinence. She was referred to a physical therapist for treatment of her condition and indicates that progress has been made. The patient has requested reimbursement for physical therapy with biofeedback and the purchase of a pelvic floor stimulator. The Health Plan has denied these requests based upon a determination that the therapies are experimental/investigational for treatment of the patient’s incontinence.It appears from the record that the patient was not thoroughly diagnosed prior to the prescription of treatment. A consultation with an urologist, an uro-gynecologist, or possibly even a neurologist would be appropriate. Cystoscopy and urodynamic studies should be done to rule out any neurological impairment.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Gemtesa for the treatment of urinary incontinence.The American Urological Association (AUA) guidelines indicate that overactive bladder occurs in the presence of urinary urgency accompanied by frequency in the absence of urinary tract infection or other obvious pathology. The AUA guidelines reveal that the beta-3 adrenoreceptor agonist, Gemtesa (vibegron), should be utilized as a second-line therapy for the treatment of overactive bladder and resulting urinary incontinence. A study indicated that anticholinergics have been used in the treatment of overactive bladder, but their use is limited by poor tolerability and anticholinergic-related side effects.

Where the denial was upheld

A 55-year-old female enrollee has requested debridement of extensive eczematous or infected skin (extensive peeling of the skin (code 11000)), pelvic ultrasound, transvaginal (code 76830), and prophylactic/therapeutic injection of estrogen (code 96372) for the treatment of her medical condition. Findings: The physician reviewer found that this patient received a variety of modalities for menopause relief. In terms of her therapy with compounded injectable and implantable estrogens, the American College of Obstetrics and Gynecology states, “The steroid hormones most commonly compounded include dehydroepiandrosterone, pregnenolone, testosterone, progesterone, estrone, estradiol, and estriol …..Most compounded products have not undergone any rigorous clinical testing for either safety or efficacy, and issues of quality assurance regarding the purity, potency, and quality of compounded produ…

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for posterior tibial neurostimulation for treatment of the enrollee’s urinary urgency. Findings: The physician reviewers found that there is evidence in the peer-reviewed literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of posterior tibial neurostimulation in patients with urinary urgency and frequency, as in this case. However, most trials have a small number of patients with short term follow-up. American Urological Association guidelines recommend that clinicians should offer behavioral therapies, such as bladder training, bladder control strategies, pelvic floor muscle training and fluid management, as first-line therapy to all patients with overactive bladder.

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