Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1The patient is a 61-year-old woman with a history of a hysterectomy and anterior and posterior repair. Upon examination in November 2003 there was some cystocele and a comment that the pelvic musculature was not very strong. In January 2004, there was a notation that the patient had been experiencing protrusion of the sling muscle into the vagina. She began receiving pelvic floor therapy and electrical stimulation of pelvic floor. The patients provider indicated the patient did not have urinary incontinence. The patient has requested reimbursement for pelvic floor therapy and electrical stimulation of pelvic floor. The Health Plan has denied this request indicating that the therapy at issue is considered investigational for treatment of weak pelvic floor muscles.Review of the submitted records indicates there has been no medical diagnosis of the patients condition. There is no urinary incontinence. Although some cystocele was noted, this is normal in a 61-year-old patient. There is apparently not even enough of a cystocele to grade as 1, 2, or 3, which is to describe its apparent protrusion in the vagina at the introitus and through the introitus, respectively. The fact that she has been experiencing protrusion of the sling muscle into the vagina is apparently a subjective feeling and does not correlate with a medical diagnosis. At best, Kegel exercises would be the only treatment prescribed to strengthen the pelvic musculature.Based upon the information set forth above, I have determined that the therapy at issue is 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 2This patient is a 61-year-old woman who has undergone hysterectomy and anterior and posterior repair. She presented with subjective complaints of vaginal prolapse and objective findings of pelvic floor musculature relaxation. She had apparently been doing Kegel exercises at home without improvement of her symptoms. As an alternative to additional surgery, her provider recommended pelvic floor therapy consisting of electrical stimulation of the weakened muscles and adjuvant home exercises. The patient completed this course of treatment and according to the records made excellent progress. The patient has requested reimbursement for the therapy at issue. The Health Plan has denied this request.It would appear that the Health Plan has equated biofeedback with electrical stimulation treatment of the weakened pelvic floor musculature, the latter of which was intended to be therapeutic in this patient. Randomized, controlled trials have indicated that electrical pelvic floor stimulation can improve urinary incontinence and this patients pelvic floor relaxation is comparable. Thus, it should be considered a treatment option apart from its association with biofeedback methods. Moreover, studies which have investigated the success of the various non-surgical treatments of pelvic floor dysfunction generally indicate a greater degree of success when there is a structured program with education, counseling and a frequent patient exercise program.Based upon the information set forth above, I have determined that the therapy at issue is 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 3The patient is a 61-year-old female who wants to improve the muscle tone of her vaginal canal. She is status post hysterectomy with anterior and posterior repair. She was on estrogen replacement, which was recently discontinued because of a cyst in her breast. The patient does not have urinary stress incontinence. Her physician recommended using pelvic floor therapy and electrical stimulation of pelvic floor as a means to help the patient improve the muscle tone of her vaginal canal. A request has been made for reimbursement for the therapy at issue. The Health Plan has denied the request on the basis that the therapy at issue is considered experimental.There is no evidence that the therapy at issue was medically indicated. Review of the submitted records indicates the patient did not have urinary incontinence. In addition, there has been no diagnosis of the patients condition. Furthermore, although the patients physician recommended pelvic floor therapy and electrical stimulation of pelvic floor to improve the patients pelvic muscle tone, there is no evidence that the therapy at issue has a statistically significant effect on the patients condition. Therefore, I have determined that the therapy at issue is 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.