Urinary Incontinence 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 biofeedback services. Biofeedback has been shown to be beneficial to the treatment of patients with urinary problems when used as supplemental therapy. In addition, data from peer-reviewed medical literature reports that biofeedback can be beneficial for patients who have failed other treatment. In this case, the patient was being managed with pessary and physical therapy. Biofeedback can help allow female patients to isolate pelvic floor accessory muscles during pelvic floor contractions, which can aide in treatment of urinary issues. Thus, pelvic floor physical therapy with biofeedback was an appropriate next step and consistent with standard of care in the management of this patient’s symptoms.

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 authorization and coverage for InTone MV incontinence treatment system (non-implant pelvic floor electrical stimulator) for treatment of the enrollee’s urinary symptoms. Findings: The physician reviewer found that Electrical stimulation is a potential treatment option for patients with urinary incontinence. The electrodes could be implantable or not, and stimulation can be long or short duration. The exact mechanism of action of the electrical stimulation is not completely understood. Reorganization of spinal reflex and regulation of cortical activity are suggested as possible mechanisms. The type of stimulation could include suprapubic, transvaginal, sacral and tibial nerve stimulation.

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