Chronic Pelvic Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an implantable peripheral nerve stimulator. The current medical literature suggests that improvements may be observed in pain scores and functionality with the use of peripheral nerve stimulation for the treatment of patients with chronic pelvic pain. One study found that after a 60-day peripheral nerve stimulation treatment, patients with chronic pain reported sustained, clinically significant improvements in pain and quality-of-life. Additionally, evidence-based clinical guidelines from the American Society of Pain and Neuroscience demonstrate evidence that peripheral nerve stimulation is indicated for the treatment of patients with complex pain disorders.

The patient is a 21-year-old female with debilitating chronic pelvic pain since 1999. She has had multiple gynecologic surgeries for diagnosis and palliation without success. She has been treated with a GnRH medication for endometriosis. She has had a negative urologic and GI workup. She has been managed pharmacologically by a pain specialist with only limited relief and has also had trigger point injections, which were not effective. She was evaluated at a pain management clinic where she was diagnosed with myofascial pain syndrome and then referred for pelvic floor physical therapy (pelvic floor therapy). She continued pelvic floor therapy for approximately six months. The patient initially seemed to respond to the therapy, but more recently has not responded, apparently due to an exacerbation of her depression. A request has been made for continued pelvic floor therapy.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for hysterectomy (CPT Code 58550). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patient’s chronic uterine pain. The submitted documentation does not support the medical necessity of the requested services. In this patient’s case, an appropriate gynecologic workup was required due to the patient’s history chronic pelvic/abdominal pain. This patient did not appear to have a complete gynecologic workup for the etiology of the symptoms presented by the gynecologist nor did the records indicate that there were any consultations for the etiology of the patient’s pain from the primary care provider or a provider with sub-specialty certification in gastroenterology, general surgery, or urology.

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injections for treatment of her medical condition. Findings: Two physician reviewers found that the use of Botox injections in clinical medicine has significantly improved management of many movement disorders, spasticity, and syndromes of autonomic over activity. In a pilot study from Australia of women with chronic pelvic pain and demonstrable spasm in the pelvic floor muscles, a reduction in pressure was found when botulinum toxin type A was injected, and a diminution of pain symptoms was noted. A follow up study of small patient numbers was performed to evaluate the treatment’s effect on pelvic floor pressure, pain response, and impact on quality of life.

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 chronic pelvic pain, then check the rights and deadlines that apply to your plan.