Prostate Problem denials in California external review
In the California DMHC record, independent physician reviewers decided 33 published external-review cases involving prostate problemand overturned the plan’s denial in 45.5%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for prostate problem
| Category | Decisions | Overturned |
|---|---|---|
| Erectile Dysfunct Rx | 5 | 60% |
| Genetic Genomic Test | 4 | 0% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 18 | 50% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 14 | 42.9% |
What the reviewers wrote
Where the denial was overturned
The patient is a 63-year-old male who has been diagnosed with prostatic enlargement, gross hematuria, and bladder outlet obstruction. On 5/23/19, the patient underwent cystoscopy and transurethral resection of the prostate (TURP). The patient required continuous bladder irrigation on postoperative day one. He was given a void trial on 5/25/19 and discharged home. The patient has requested reimbursement for an inpatient hospital stay from 5/24/19 through 5/25/19. The Health Plan denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether an inpatient hospital stay from 5/24/19 through 5/25/19 was medically necessary for the treatment of the patient’s medical condition. Hematuria is the most common complication of TURP procedures in the immediate postoperative period.
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.
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 reimbursement for Genetic testing (Oncology (prostate) gene expression profile by real-time polymerase chain reaction (RT-PCR) of three genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score). This patient presents with elevated prostate specific antigen (PSA) and benign prostatic hyperplasia (BPH). The patient underwent ExoDx testing, which revealed a 91% chance of no high grade prostate cancer. As noted in the peer-reviewed medical literature, the use of ExoDx testing to forego biopsy in patients with increasing PSA and negative magnetic resonance imaging (MRI) has not been demonstrated to improve clinical patient health outcomes.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 prostate problem, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY