Pelvic Floor Dysfunction denials in California external review

What the reviewers wrote

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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for biofeedback training, perineal muscle, anorectal or urethral sphincter for treatment of the enrollee’s pelvic floor dysfunction. Findings: The physician reviewer found that found there are a number of causes for obstructed defecation syndrome and pelvic floor dysfunction, including rectocele, rectal intussusception, paradoxical muscular contraction, descending perineum syndrome, sigmoidoceles, or enteroceles. Some of these are structural anatomical issues, but others are functional issues with normal anatomy. If functional abnormalities are present, lifestyle modification and biofeedback therapy can be effective.

Where the denial was upheld

Physician 1The patient is a 61-year-old woman with a history of a hysterectomy and anterior and posterior repair. Upon examination in November 2003 there was some cystocele and a comment that the pelvic musculature was not very strong. In January 2004, there was a notation that the patient had been experiencing protrusion of the sling muscle into the vagina. She began receiving pelvic floor therapy and electrical stimulation of pelvic floor. The patient’s provider indicated the patient did not have urinary incontinence. The patient has requested reimbursement for pelvic floor therapy and electrical stimulation of pelvic floor. The Health Plan has denied this request indicating that the therapy at issue is considered investigational for treatment of weak pelvic floor muscles.Review of the submitted records indicates there has been no medical diagnosis of the patient’s condition.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for physical therapy twice per week. Findings: The physician reviewer found that the request for authorization and coverage for physical therapy twice per week is not medically necessary for treatment of this patient’s symptoms. The documentation indicates that the patient has been evaluated by physical medicine and rehabilitation, pain management, and gynecology specialists. The impression is that the patient’s condition is low back/sacroiliac related. However, the records report that prior physical therapy has not led to functional improvement. The provider noted that the patient was also treated with prior therapy for pelvic floor dysfunction without improvement.

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 pelvic floor dysfunction, then check the rights and deadlines that apply to your plan.