Fecal Incontinence: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient requested authorization and coverage for biofeedback peri/uro/rectal (units: six). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patient’s medical condition. The submitted documentation supports the medical necessity of the requested services. Medical research by Alame (cited above) and Thapar (also cited above) has showed that there are a number of causes for constipation related to obstructed defecation syndrome, (per the symptoms in this case), and pelvic floor dysfunction, (per the testing in this case), such as rectocele, rectal intussusception, paradoxical muscular contraction, descending perineum syndrome, sigmoidoceles, or enteroceles. Some of these potential causes are structural anatomical issues.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for wheelchair accessories including a rain canopy and under seat storage basket, with the approved wheelchair. Canopies are generally considered to be convenience items when attached to wheelchairs or medical strollers. Exceptions include when there is a medical need to block the sun, such as a hypersensitivity syndrome to the sun from medications or in certain medical conditions. In this case, the patient has autism, and the patient becomes overstimulated by exposure to the sun, leading to agitation. This is a reasonable medical reason for a canopy as people with autism commonly cannot tolerate certain environmental exposures, such as excessive light, noise, and crowds.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a pelvic floor electric stimulation device. Several randomized controlled trials have reported mixed results with electrical stimulation for treating fecal incontinence. One study evaluated patients with fecal incontinence treated with a home electric stimulation device for eight weeks. The authors found that there was no statistically significant difference between groups in patient reports of symptom changes. In addition, systematic reviews of randomized controlled trials have not revealed that electrical stimulation is superior to control interventions for treating fecal incontinence.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for biofeedback therapy. The submitted documentation supports the medical necessity of the requested services. The records document fecal incontinence unresponsive to conservative therapy including medications and pelvic floor exercise. The American Society of Colon and Rectal Surgeons’ Clinical Practice Guideline for the Treatment of Fecal Incontinence states that “biofeedback should be considered as an initial treatment for patients with incontinence and some preserved voluntary sphincter contraction.” The American College of Gastroenterology guideline for the management of benign anorectal disorders states that pelvic floor rehabilitative techniques such as biofeedback are effective and superior to pelvic floor exercises alone in patients with fecal incontinence who do not respond to conser…

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for fecal incontinence was denied, the published record says the denial is worth fighting.