Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Groin Pain
Treatment: Outpatient Surgery (64630x1) Pain Management, Pre-service
The insurer denied the Outpatient Surgery (64630x1) Pain Management, Pre-service.
The denial is overturned.

The patient is a female with diagnosis of pudendal neuralgia secondary to ulcerative cystitis. She is status post bilateral pudendal nerve radiofrequency ablation under monitored anesthesia care after successful but short-lasting pudendal nerve blocks with greater than 90% relief lasting three to four months; last radiofrequency was done earlier in the year. The patient has tried heating pads, ice packs, medications, physical therapy and home exercise program. The request is for bilateral pudendal nerve radiofrequency ablation.

Yes, the proposed treatment is medically necessary.
Per Elkins, pelvic neuralgias frequently cause severe pain and may have associated bladder, bowel, or sexual dysfunctions which also impact quality of life. This article explores the etiology, epidemiology, presentation and treatment of common causes of neurogenic pelvic pain, including neuralgia of the border nerves (ilioinguinal, iliohypogastric, and genitofemoral), pudendal neuralgia, clunealgia, sacral radiculopathies caused by Tarlov cysts, and cauda equina syndrome. Treatment of pelvic neuralgia includes conservative measures such as pelvic physical therapy, lifestyle modification, and medications with escalation to more invasive and novel treatments such as nerve blocks, radiofrequency ablation, cryoablation, neuromodulation and neurectomy/neurolysis if conservative treatments are ineffective.

Per Perez-Lopez, pelvic pain is a frequent complaint in women during both reproductive and post-reproductive years. Vulvodynia includes different manifestations of chronic vulvar pain with no known cause. Many women do not receive a diagnosis and appropriate treatment. Pudendal neuralgia is a painful condition caused by inflammation, compression or entrapment of the pudendal nerve; it may be related to or be secondary to childbirth, pelvic surgery, intense cycling, sacroiliac skeletal abnormalities or age-related changes. Clinical characteristics include pelvic pain with sitting which increases throughout the day and decreases with standing or lying down, sexual dysfunction and difficulty with urination and/or defecation. To confirm pudendal neuralgia, the Nantes criteria are recommended. Treatment includes behavioral modifications, physiotherapy, analgesics and nerve block, surgical pudendal nerve decompression, radiofrequency and spinal cord stimulation.

This patient has bilateral pudendal nerve pain secondary to ulcerative cystitis. She is status post bilateral pudendal nerve radiofrequency (RF) ablation under monitored anesthesia care after successful but short-lasting pudendal nerve blocks with greater than 90% relief lasting three to four months; last radiofrequency done earlier in the year. She has tried heating pads, ice packs, medications, physical therapy and home exercise program. The request is for bilateral pudendal nerves radiofrequency ablation.

Given the information that the patient has tried and failed conservative treatment and has had positive relief from the previous radiofrequency ablation, the request is medically necessary.

The patient has tried and failed conservative treatment and has had positive relief from the previous radiofrequency ablation; therefore, the request is medically necessary using evidence-based guidelines.