Interstit Cystitis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Solu-Cortef, Marcaine, heparin, Lidocaine and sodium bicarbonate mixture for bladder instillation. Findings: The physician reviewer found that the patient ihas intractable interstitial cystitis. the patient is noted to have significant painful voiding syndrome. The patient has had multiple therapies in the past including numerous oral agents. The patient has had sacral nerve stimulator inserted resulting in improvement in her voiding symptoms. However, she continues to have significant painful voiding syndrome with suprapubic pain. This has been quite disabling. She has tried subsequently pelvic floor therapy and diet. The patient reported significant improvement with intravesical therapy.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly in-office injections of Rimso-50. The records provided for review document that this patient presents with a history of interstitial cystitis. Per the provider’s reports, the patient has been treated with several medications including antibiotics, Pyridium, oxybutynin, Uribel, hyoscyamine, and Elmiron without success. Based on the American Urological Association (AUA) guidelines on interstitial cystitis, this patient has failed treatment with first and second-line therapies for interstitial cystitis. Clinical studies have shown that Rimso-50 is safe and effective in treating patients with interstitial cystitis and bladder pain syndrome.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for tramadol daily.Guidelines state that when opioid therapy is used, a patient’s regimen should include nonpharmacologic therapy and nonopioid pharmacologic interventions. Additionally, they noted that “Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.”Guidelines states, “Continuation, modification or termination of opioid therapy for pain is contingent on the clinician’s evaluation of (1) evidence of the patient’s progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion.” Further, they strongly recommends prescribers use “opioid therapy for chronic pain that is not cancer-related, or part of pallia…

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ruxience (rituximab-pvvr) administered as two infusions separated by 15 days. In this case, it is not clear if this patient has lupus. The results of a renal biopsy in the provider’s letter dated 6/30/23 did not mention immunofluorescence. Many conditions can cause interstitial nephritis and worsening renal function. In this case, based on normal complement and no mention of positive immune complexes on immunofluorescence, it appears that the patient does not have lupus nephritis. A positive result on either of these would indicate treatment for lupus.

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