Overactive Bladder denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for percutaneous tibial nerve stimulation (PTNS) treatments for treatment of the enrollee’s overactive bladder. Findings: 2/3 of the physician reviewers found that the PTNS treatments in dispute were likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. PTNS is considered to be an appropriate salvage therapy for patient with intractable irritative lower urinary tract symptoms including urgency and incomplete emptying. According to the documentation submitted for review, the patient is symptomatic with overactive bladder symptoms including urgency. The patient has failed multimodal therapy. The patient responded well to PTNS treatments.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS). The American Urological Association (AUA) guidelines on diagnosing and treating idiopathic overactive bladder explain, in Statements 11 through 14, that treatment of overactive bladder often follows a stepwise approach, with non-invasive/medication strategies employed first. In this case, consistent with these guidelines, the patient was first offered strategies such as pelvic floor physical therapy, behavioral modification, and bladder training. The patient did not respond to these treatments and, consistent with AUA guideline Statements 16, 20, and 21, was started on numerous oral medications.

Where the denial was upheld

Physician 1: This patient is a 53-year-old female who presented in December 2004 with a one-year history of urinary urgency and frequency every one-half hour during the day (about 50 ml each time) and hourly at night. On examination she was overweight. Urinalysis was normal. Cystoscopy under local anesthesia was normal with bladder capacity noted to be 400 ml and residual urine volume only 5 ml. CT scan of the abdomen and pelvis in January 2005 revealed a gallstone and ovarian cysts.In January 2005 it was reported that treatment with anti-spasmodic medications Levbid and Ditropan, had not helped. Urodynamics testing was performed in March 2005. First sensation of bladder filling was noted at 400 ml, first urge to void occurred at 425 ml, and at 500 ml she voided, with appropriate bladder contractions. Urethral pressures were reportedly high and the bladder neck did not relax.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation once a month for treatment of the enrollee’s overactive bladder. Findings: 2/3 of 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 percutaneous tibial nerve stimulation 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. The current guidelines recommend that clinicians should offer behavioral therapies (e.g., 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 overactive bladder, then check the rights and deadlines that apply to your plan.