Pelvic Inflam Dis denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 33-year-old female who was diagnosed with vulvodynia in 2003. She was treated by her gynecologist with topical estrogen, anti-inflammatory creams, antifungal preparations and Elavil, all without apparent success. The patient was referred to an out-of-network provider who specializes in the treatment of vulvodynia. The out-of-network provider instituted treatment with manual therapy and a pudendal block, which has resulted in considerable relief of her pain. The patient has requested authorization and coverage for a referral to a physician who specializes in vulvodynia. The Health Plan has determined the requested referral is not medically necessary for treatment of the patient’s medical condition.Vulvodynia is an enigmatic disorder, which falls into the broad spectrum of pelvic pain and perhaps into the even broader spectrum of chronic systemic pain disorders.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for percutaneous tibial nerve stimulation (PTNS) treatments for treatment of the enrollee’s overactive bladder. Findings: 2/3 of the physician reviewers found that the PTNS treatments in dispute were likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. PTNS is considered to be an appropriate salvage therapy for patient with intractable irritative lower urinary tract symptoms including urgency and incomplete emptying. According to the documentation submitted for review, the patient is symptomatic with overactive bladder symptoms including urgency. The patient has failed multimodal therapy. The patient responded well to PTNS treatments.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for radiofrequency ablation (RFA). With regards to the evidence surrounding pudendal nerve treatment, one review noted that although surgery seems to provide a higher proportion of long-term benefits, identifying the most efficient therapeutic approach is made difficult by the multitude of outcome measurements and follow-up frequencies. The authors also note that “literature is sparse regarding randomized controlled trials with long-term follow-up”. Another review concluded that, “Emerging techniques such as pulsed radiofrequency ablation… are promising; however, more studies are needed to evaluate safety and effectiveness. Current study data is generally poor, and unstandardized.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox injection to the pelvic muscles (CPT code 20553 – trigger point injection(s) x 1 and HCPCS code J0585 – injection, onabotulinumtoxinA 1 unit x 200). A review conducted by Karp and colleagues evaluated the effectiveness of Botox for chronic pelvic pain in the current medical literature. The authors found data supporting that Botox “can be safely and tolerably injected into pelvic floor muscles in women as an outpatient procedure.” Gari and colleagues noted that there is “promising evidence to support the use of Botox in cases of refractory pelvic floor muscle dysfunction.” The authors concluded that, “Further randomized controlled trials are warranted to standardize the use of Botox as a treatment option for these cases.” This patient’s records document chronic pelvic pain refractory…

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 inflam dis, then check the rights and deadlines that apply to your plan.