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. 

According to the documentation provided, the patient was a female with a history of bilateral core muscle injury. Prior physician consultation notes, diagnostic imaging and physical therapy notes were submitted and reviewed. The patient was seen where the history was noted of pain with postural movement, running, and with activities of daily living. The physician noted that the patient had been having pain in her groin, much worse on the left side than the right side since about a year ago. The patient is an avid runner and does some cross-training. The patient's pain probably was worse when she finished doing some snowboarding this past spring. On exam, the patient had pain with resisted sit ups and resisted adduction on both sides but mainly on the left at the adductor insertion site of the pubic bone. The physician reviewed the patient's magnetic resonance imaging (MRI) which showed severe midline plate detachment extending to both sides with extension to the right greater than the left. There was more inflammation down at the patient's pubic plate level on the left side and mild right distal rectus abdominis atrophy compared to the left side. The patient also had a Grade 1 strain of the left obturator externus muscle. The patient recommended repair of the core muscle. The patient's MRI of the bony pelvis was done which revealed severe midline core muscle injury and mild to moderate bilateral hip pathology. The patient's MRI showed sprain of the abductor aponeurosis with a deep surface tear and reactive bone edema on both sides of the pubic symphysis. The patient's MRI done showed osteitis pubis and left greater than right sacroiliitis with a moderate left gluteus tendinosis without disruption associated with trochanteric bursal thickening bilaterally. The patient had been previously seen by the doctor who recommended surgery. The patient was seen by the doctor who recommended referral for athletic pubalgia surgery. The patient was seen previously by the doctor who recommended corticosteroid injections. The patient underwent physical therapy in without improvement of symptoms. The patient underwent bilateral pelvic repair, bilateral adductor longus and pectineus repair, bilateral adductor longus and pectineus compartment decompression and steroid injection.
Based upon the review of the medical record and literature, this patient is a good candidate for sports hernia surgery as she has a core muscle injury as documented on this patient's MRI which had not healed despite conservative therapy. There is considerable literature and the pathophysiology of this sport injury is such that it is a variant of a hernia with a spectrum of injury to the inguinal canal in athletes who have persistent groin or abdominis recti pain. Pelvic floor repair refers to a broad surgical reattachment of the inferolateral edge of the rectus abdominis muscle with its fascial investment to the pubis and adjacent anterior ligaments. Based upon the recommendations of the doctor and the findings, the patient was an appropriate candidate for this repair. The patient had been diagnosed with a core muscle injury and she had been given the recommendation to undergo surgical repair as the patient did not improve with physical therapy and rest. 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.