Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Athletic Pubalgia
Treatment: Core Muscle Surgery Repair
The insurer is denied coverage for Core Muscle Surgery Repair. 
The denial is reversed. 

This was a female with a history of bilateral core muscle injury. The patient was physically very active with running and snowboarding until she began experiencing sharp stabbing pelvic pain. The pain was initially managed with rest and ibuprofen but worsened and progressed to groin and back pain exacerbated by walking or any physical activity. The patient was seen by a doctor of sports medicine since the pain worsened with activity. A pelvic stress fracture was ruled out by imaging, and a home exercise program was started. The patient's pain was worsened after a few weeks, and the nocturnal stabbing pain also returned. The patient's magnetic resonance imaging (MRI) was performed which showed osteitis pubis. The patient was then evaluated by the doctor since her symptoms persisted, and physical therapy and meloxicam were recommended. The patient continued physical therapy for \months with worsening of her pain. The patient was then referred to the doctor who recommended surgery for the tear. The patient then saw another doctor and the patient's repeat MRI demonstrated severe midline core muscle injury (bilateral full thickness labral tears, left obturator externus muscle strain, continued edema and aponeurotic plate injury) with severe osteitis pubis. The doctor performed bilateral pelvic floor repair, bilateral adductor longus and pectineus repairs, and bilateral adductor longus and pectineus compartment decompression with dramatic improvement in her pain per the patient. The patient underwent postoperative physical therapy followed by a second surgery to treat a femoroacetabular impingement and labral tears.
The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. The consensus across the literature is that a period of conservative or non-surgical therapy should be initially attempted and includes rest, non-narcotic analgesics, and physical therapy. There is very little data examining the effectiveness of non-surgical therapy, however. A prospective, randomized trial performed by Paajanen et al (2011) comparing physical therapy with surgical repair (a laparoscopic mesh repair) for sports hernias demonstrated that 7 of 30 patients in the non-surgical arm converted to the surgical arm because of continued symptoms, and only 50% of those patients returned to sports at one year. Twenty-nine of 30 patients in the surgical arm returned to full sports and were free of pain at one-year follow-up. This patient had a lengthy period of rest, use of NSAIDs, meloxicam without any relief of her symptoms. Her pain actually increased while undergoing physical therapy.
Core muscle surgery repair is a general term describing a multitude of procedures that are performed, depending on the pathology encountered in each patient and the expertise and experience of each surgeon. Surgical therapies can include open repair of the rectus abdominis, external oblique, transversus abdominus, or transversalis fascia, repairs with mesh reinforcement, laparoscopic repairs, and broad pelvic floor repairs with or without adductor release. All of these surgical options are variations of the standard hernia repair which is well established and well described in the general surgery teaching and literature. No final approval is required from any regulatory bodies for this diagnosis.
This patient is an excellent candidate for core muscle surgery repair, procedure code 49999, performed. The patient had pursued an unsuccessful course of non-surgical therapy including rest, ice, the use of NSAIDs, and physical therapy for a period of over a year before surgical therapy was recommended. The core muscle surgery repair is the best available treatment for this patient. The patient had followed a long course of non-surgical therapy with no relief, and was now experiencing worsening of her symptoms. Thus, the requested procedure is likely to be more beneficial than any of the standard treatments/procedures for this patient.
The carrier's denial of Core Muscle Surgery Repair, procedure code 49999, should be reversed.