Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries
Treatment: Surgical Services

Diagnosis: Other- Trauma/Injuries-Other-groin/abdominal pain
Treatment: Surgical Services- Pelvic floor repair
The health plan denied the outpatient surgery as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This patient had a complaint of right groin and adductor pain of 2 years duration. He consulted with the surgeon for this condition. He has undergone prior right hip surgery and he has had prior left inguinal hernia surgery. The submitted records reference two magnetic resonance imaging (MRI) reports. The first MRI report describes anatomic changes of prior right femoral head/neck osteochondroplasty. The lower abdominal musculature and aponeuroses are preserved without acute tear or arthrosis of the pubic symphysis. The adductor tendon origins and proximal adductor myotendinous junction and muscles are not torn. There was also a small fat filled right inguinal hernia. Per the surgeon's review of this MRI, it did show a midline myofascial abdominal wall defect. The second MRI findings were that of severe detachment of the midline rectus abdominus-adductor plate extending to both sides (right greater that left).
Because of persistent groin pain and symptoms of core muscle injury, the patient underwent bilateral pelvic floor repairs, mobilization of mesh on the left side, bilateral rectus abdominis compartment decompressions, bilateral adductor longus, pectineus and adductor brevis compartmental decompressions and repairs, and steroid injection.
The medical records submitted for review do not support the medical necessity of the operation performed. They do not include any documentation of alternative therapeutic treatment attempts such as rest, non-steroidal anti-inflammatory drugs (NSAIDs), steroid injections, or physical therapy. There is discrepancy between the two MRI studies with one showing no specific abdominal wall pathology other than a right inguinal hernia and the other MRI showing severe detachment of the midline rectus abdominus-adductor plate extending to both sides (right greater that left). Therefore, the medical necessity of the operation  cannot be established. This patient is reported to have chronic right groin pain, however, there are no clinical records submitted that document the chronicity of the condition and support the medical necessity of the surgical therapy as performed. There is no submitted documentation of myofascial abnormalities on pelvic imaging performed outside of the treating physicians center.
Pelvic floor repair, although not widely performed, is not experimental or investigational and is medically necessary when performed in the appropriate clinical circumstance. Groin or lower abdominal pain is a common and complex symptom, particularly among athletes, that presents a challenging management problem. Because of the various anatomical structures involved, patients with sports related injuries of the groin and pelvic floor may be referred to orthopedic, urological, sports medicine specialists, or general surgeons. The assessment of these patients includes careful history and physical examination and appropriate diagnostic studies. Groin pain can also require a multidisciplinary assessment and treatment approach with rest, NSAIDs, steroid injections, and physical therapy. Appropriate documentation is not submitted for review at this time.