Incontinence Supplies denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for incontinence supplies including large/x-large Pull-Ups. In this case, the patient presents with moderate to severe autism and developmental delays. As noted in the medical literature, incontinence supplies may be considered medically necessary if they are required to manage or treat a medical condition. Per a review of the literature, bladder and bowel incontinence is common in pediatric patients with autism. There are many challenges to proper toilet training in this patient population. Overall, the efficacy of treatment varies depending on patient characteristics such as age and severity of the underlying developmental disability. In this case, the patient has incontinence.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for incontinence supplies including pediatric-sized disposable diapers, underpads, wipes, and gloves. On review of the current medical literature, bladder and bowel incontinence are commonly associated with pediatric patients with global developmental delays. There are many challenges to proper toilet training in this patient population. Generally, behavioral approaches are used with varying efficacy depending on patient characteristics such as age and severity of the underlying developmental disability. In this case, the patient has incontinence due to Angelman syndrome, which is caused by chromosomal deletion, and characterized by severe developmental delays.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wipes.Researchers state that risk factors for development of incontinence-associated dermatitis include compromised skin (e.g., due to aging, steroid use or local trauma/friction), immobility, decreased cognitive awareness, inability to perform personal hygiene, pyrexia, and poor nutritional status. Due to a lack of high quality experimental literature, prevention and treatment of incontinence-associated dermatitis is largely guided by expert opinion and focused on addressing the incontinence itself when feasible, timely clean up following incontinent episodes, and applying skin protectants, such as barrier creams.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for Huggies brand incontinence diapers. Daytime urinary incontinence is common in the pediatric population and affects approximately 7-10% of children aged five to thirteen years. Risk factors for incontinence can be genetic, demographic, environmental, behavioral, or physical. In this case, the patient is 17 months old, and is not yet expected to be continent. As part of routine infant and toddler care, diapers are not medically indicated for the patient at this time.

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 Incontinence Supplies, then check the rights and deadlines that apply to your plan.