Interstitial 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 acupuncture for two to three months. On review of the available documentation, this patient presents with interstitial cystitis. The patient has undergone treatment with physical therapy, medications, as well as modifications in her diet without adequate relief of her symptoms. The patient’s provider has recommended treatment with acupuncture. The current peer-reviewed medical literature supports a trial of acupuncture to address this patient’s interstitial cystitis. Medical literatures reported that, “Therapies with the potential for benefit in patients with bladder pain syndrome are dietary management, acupuncture and physical therapy.” The authors noted that complementary alternative medicines for patients with interstitial cystitis can include acupuncture.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) hydrocodone 10 mg, four times a day, or (2) hydrocodone 10 mg, three times a day. Findings: The physician reviewer found that when to initiate or continue opioids for chronic pain, Dowell and colleagues report, “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS) provided for treatment of the enrollee’s interstitial cystitis. Findings: 2/3 of the physician reviewers found that the procedure for PTNS consists of the insertion of a needle above the medial malleolus into the posterior tibial nerve followed by the application of low-voltage (10 mA, 1-10 Hz frequency) electrical stimulation that produces sensory and motor responses. Noninvasive PTNS has also been delivered with surface electrodes. The recommended course of treatment is an initial series of 12 weekly office-based treatments followed by an individualized maintenance treatment schedule.

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