Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Overactive bladder.
Treatment:  Ambulatory surgery, outpatient services (64581, 64590) x 1.

The insurer denied coverage for Ambulatory surgery, outpatient services (64581, 64590) x 1.  The denial is overturned.
 
This case involves an adult with a history of osteoporosis, scoliosis, Crohn's disease, and overactive bladder. The patient underwent a Deflux injection. The patient presented for an evaluation related to frequency of urination for the past few years. She was treated with Elmiron for several months in the past without improvement. She was given lidocaine installations for a few weeks without improvement. She was trialed on Cymbalta and developed chest pain. She was recommended to start pelvic floor relaxation therapy for pelvic floor dysfunction. The provider opted to hold off on physical therapy, due to exquisite tenderness of the pelvic floor. It was stated that the patient had no significant response from techniques of pelvic floor relaxation coupled with diazepam dosing. The patient had a complex urological and gynecological history. She had bilateral salpingo-oophorectomy and hysterectomy. The patient had removal of the right renal unit. The patient was seen for an evaluation. The patient complained of a great deal of pain. She was utilizing oxycodone tablets and had no further medications for pain relief. She had found diazepam to be somewhat helpful. She had not undergone therapy. The patient's problems and pain issues were complex. She had some initial response to anesthetic installations into the bladder. However, she had become refractory. The provider recommended moving forward with Dimethyl sulfoxide (DMSO) installations. She was to continue her techniques of pelvic floor relaxation. They would continue diazepam dosing for the time being. The provider noted that the patient may be best suited for a long-acting opioid. There was consideration for trigger point injections coupled with pudendal nerve blocks. The patient was started on Pyridium. The provider noted that the patient only had transient improvement with hydraulic distention of the bladder. There was consideration for Botox injection. It was noted that the patient underwent peripheral nerve evaluation with greater than 50% reduction in frequency and much less urge episodes. The provider recommended stage 1 and 2 Axonics neurosacral stimulator insertion under fluoroscopy.

In this case, the patient had a history of overactive bladder. The patient had received extensive diagnostic work-up and had been treated with lidocaine installations, Elmiron, oral medications, pelvic floor relaxation therapy, surgery, and rest. The patient underwent sacral nerve stimulator trial with benefit. The provider recommended stage 1 and 2 Axonics neurosacral stimulator insertion under fluoroscopy. While it was unclear if the prior pelvis floor training was directed by a physical therapist with biofeedback and bladder training, the documentation did detail failure of pelvic floor relaxation therapy. Taking into consideration updated literature, biofeedback, therapist directed treatment, and bladder training are not criteria which must be met to establish trial and failure of appropriate pelvic floor relaxation therapy and bladder training. The patient has been treated extensively for years without meaningful improvement. It is unlikely that additional pelvic training with or without bladder training and biofeedback would result in sustained functional improvement. Thus, it is medically necessary and supported per current literature to proceed with the requested surgical intervention.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for ambulatory surgery, outpatient services (64581, 64590) x 1 is substantiated.