Bunion: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom molded foot orthotics for both the right foot and left foot.Custom orthotics have been historically utilized as a conservative standard of care treatment for plantar fasciitis and metatarsalgia. Oftentimes, orthotics will be utilized for bunion and hammertoe pain as well, with specialty pads added to the orthotic to offload painful areas of the feet. Orthotics are useful in the treatment of plantar fasciitis, metatarsalgia, bunions, and hammertoes, as they alter the abnormal biomechanics of the foot, allowing for a more normal foot structure and gait. This will oftentimes alleviate the patient’s foot pain. In this case, the patient reports painful bilateral plantar fasciitis, difficulty walking, bunion pain and hammertoe pain.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for orthotic inserts. Current medical literature indicates that posterior tibial tendinitis and bunion deformities are caused by significant eversion of the heel, with significant subtalar joint valgus. This abnormal mechanical positioning causes severe stress to both the posterior tibial tendon as well as the first metatarsophalangeal joint (MPJ). Standard of care for this patient includes custom functional orthotics to reduce calcaneal eversion and overpronation which will alleviate stress and strain from the posterior tibial tendon, first MPJ, and sinus tarsi.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for an electric scooter. The enrollee has worsening pain in both feet. A progress note includes diagnoses of corns and callouses, and pain to bilateral feet and ankles. The patient was evaluated by her treating physician. Medical records show the patient had bilateral bunions, with thick tender callusing of both feet. However, there were no focal deficits. The upper and lower extremity motor and sensory examinations were described as normal and intact; respectively. The patient was assessed for an electric scooter by a physical therapist. The therapist reported the patient is fully ambulatory, without the use of a device, such as a cane, and was not restricted from driving a motor vehicle.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the ice machine combined cooling/heating device. Review of current medical literature does not indicate that the ice machine combined cooling/heating device provided was likely to be more beneficial for the treatment of the patient’s condition than any standard available therapy. While researchers reported that “continuous flow cold is superior to crushed ice for outpatient ACL [anterior cruciate ligament] reconstruction pain and should not be considered an equivalent modality”, there is a paucity of data demonstrating that the device results in superior health outcomes in bunion surgery.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for bunion was denied, the published record says the denial is worth fighting.