Urology Procedures denials in California external review

What the reviewers wrote

Where the denial was overturned

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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Rezum transurethral destruction of prostate tissue (CPT/HCPCS codes 53854, 96372, and J1885). This patient presented with a diagnosis of benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. He has failed conservative treatment with medical BPH management. He underwent further work-up, which revealed a prostate size less than 80 grams and presence of a median lobe. BPH is non-cancerous enlargement of the prostate which often causes urinary obstruction leading to lower urinary tract symptoms of weak stream, frequency and nocturia. Treatment begins with medical management including alpha blockers, 5-alpha reductase inhibitors, or a phosphodiesterase inhibitor.

Where the denial was upheld

The patient is a 66-year-old male with a diagnosis of prostate adenocarcinoma in 1997. He had a Gleason score total of 9 on biopsy and his PSA was approximately 7. He was then treated with hormonal therapy and radiation therapy. His PSA reached a nadir near zero, but began to rise in 2004, reaching levels of 14.9, 20.1, and 31 (according to different physician reports) with hormonal therapy changes and with ketoconanole. The submitted information indicates a bone scan performed around January 2005 was reportedly negative. In addition, an abdominal and pelvic CT scan performed in May 2005 showed no metastatic disease or prostatic enlargement. The results of a Prostascint scan reportedly showed uptake in the prostatic bed and in the aortocaval region. An oncologist has suggested consideration of salvage (radical) prostatectomy, and the patient wishes to undergo this procedure.

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 urology procedures, then check the rights and deadlines that apply to your plan.