Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1:  The patient is a 45-year-old female with a 20-year history of urinary urge incontinence and a more recent history of stress incontinence. She was referred to a physical therapist for treatment of her condition and indicates that progress has been made.  The patient has requested reimbursement for physical therapy with biofeedback and the purchase of a pelvic floor stimulator. The Health Plan has denied these requests based upon a determination that the therapies are experimental/investigational for treatment of the patients incontinence.It appears from the record that the patient was not thoroughly diagnosed prior to the prescription of treatment.  A consultation with an urologist, an uro-gynecologist, or possibly even a neurologist would be appropriate.  Cystoscopy and urodynamic studies should be done to rule out any neurological impairment. When a complete diagnosis is made, appropriate medical treatment can then be instituted. If medical treatment fails and surgery is indicated, then perhaps physical therapy with or without biofeedback may be an appropriate option. In general, physical therapy and biofeedback are considered experimental and investigational for the treatment of urinary incontinence, but may be appropriately prescribed in a situation where all other modalities were tried and found not to be effective which is not the case for this patient. Based on the patients circumstances described above, I have determined that the therapy and device at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 45-year-old female who presented with a 20-year history of having to void every 20-120 minutes throughout the day and approximately three times during the night. She reported rare urge and stress incontinence. Her urinary symptoms definitely had a negative impact on her lifestyle. The patient was referred for evaluation by a gynecologist and diagnosed with pelvic floor muscle instability.  Detrol was prescribed and the patient was referred for pelvic floor muscle physical therapy (PFM PT). The patient underwent PFM retraining which included biofeedback and electrical stimulation. After two months of therapy, she showed improvement in the forum of decreased urgency from approximately 15 times a day to five times a day and nocturia decreased from two to three times per night to one to two times per night.  She also purchased a pelvic floor stimulator for use at home.  The patient now requests reimbursement for the physical therapy and the stimulation device. The Health Plan considers the therapy experimental/investigational and has denied coverage.The patients condition is more accurately described as pain and urgency with urination rather than simple incontinence. With this clarification, the patients history is consistent with urethral syndrome which is defined as urinary urgency/frequency with or without pelvic pain. Urethral syndrome is felt to be caused by dysfunctional pelvic floor muscles and is often considered to represent the beginning of a spectrum of disorders which often progresses to interstitial cystitis. As such, it falls into the ill-defined and broad category of pelvic pain.The treatment of patients with urethral syndrome presents a frustrating clinical challenge for both physician and patient, as there is no standard therapy. However, PFM PT has become an accepted and successful mode of therapy, presumably accomplishing relief by arresting neurogenic triggers and decreasing central nervous system sensitivity. The conclusion that PFM PT is successful and has become an accepted treatment is well documented in the literature. In one study of 42 patients with urgency/frequency, 83% were reported as having had moderate to marked improvement in symptoms following PFM PT. Several review articles also attest to the efficacy of PFM PT modalities for treatment of urethral syndrome and related disorders.  The American College of Obstetricians and Gynecologists has also reported observational studies indicating improvement in 65-70% cases.  Physical therapy, biofeedback and the use of a pelvic floor stimulator are all integral parts of PFM PT. Biofeedback, for example, is necessary to confirm to the patient that she is isolating the correct muscle during treatment.  The record does document that the patient experienced this problem and biofeedback was used to overcome the obstacle. The stimulator likewise effects a more passive muscle relaxation which reinforces the patients own efforts.  In summary, this patient has experienced an ill-defined but debilitating problem for 20 years. Although there exists no standard therapy for urethral syndrome, PFM PT has been used successfully for many years and its use is validated in the medical literature.Based upon the information set forth above, I have determined that the therapy and device at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: The patient is a 45-year-old female who has a long history of urinary urgency and bladder pressure. She also has nocturia and recently, she has begun to lose urine with coughing or sneezing. The patient has received physical therapy with biofeedback and has purchased a pelvic floor stimulator.  She is requesting reimbursement for all of the related therapy.  The Health Plan has denied her request therapy citing the experimental/investigational nature of the therapy. Physical therapy in association with pelvic floor training has been found to be effective in improving genuine stress and mixed incontinence. Biofeedback and pelvic floor stimulation are typically components of the therapy. Although it is true that biofeedback has not been studied separately from pelvic floor training, the two are not separate from each other and therefore, there appears to be no need for studying biofeedback alone. Therefore, I have determined that the therapy and device at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.