Foot Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for a magnetic resonance imaging (MRI) study.According to the American College of Radiology (ACR) appropriateness criteria, an MRI of the foot may be appropriate for further evaluation of persistent foot pain after initial negative radiographs. An MRI can assist in the evaluation of soft tissue and bony pathology that is not visualized on an x-ray. Further, an MRI is also more sensitive and specific to determine the patient's underlying pathology for their pain. Cross-sectional imaging, such as MRI, can assess additional pathology not seen with x-rays, including inflammatory diseases, benign tumors, tumor-like lesions, and vascular abnormalities, among others.

Nature of Statutory Criteria/Case Summary: An enrollee has requested acupuncture services for treatment of her medical condition. Findings: The physician reviewer found that while studies on the effects of acupuncture for the treatment of foot pain are limited, there is data supporting the use of acupuncture as an effective modality for those experiencing chronic pain. A paper noted that significant differences in results between true and sham acupuncture, which indicates acupuncture is more than a placebo. In this patient’s case, review of the submitted clinical documentation demonstrates that the patient has undergone multiple attempts at treatment of her foot pain without benefit. According to the submitted documentation, the patient continues to experience severe symptoms and impairment of her daily activities secondary to her unrelieved foot pain.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for two (2) additional acupuncture treatments.Peer reviewed literature recommends an initial trial of five to six acupuncture appointments in combination with a conditioning program of aerobic and strengthening exercises to stimulate self-reliance. Future acupuncture appointments should be tied to improvements in objective measures to justify an additional 6 sessions, for a total of 12 sessions. Additional treatments should only occur based on progressively greater, incremental objective gains. In addition, passive care (acupuncture) should be combined with active care (conditioning-aerobic-stretching exercise program) to stimulate self-care and avoid medical dependency.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma (PRP) injections to the bilateral feet. Overall, the medical literature remains inconclusive regarding the long-term safety and efficacy of PRP injections in the treatment of patients with foot pain. This patient’s records document previous treatment with multiple conservative therapies such as physical therapy, orthotics, supportive shoes and non-steroidal anti-inflammatory drugs. The provider noted that treatment with local cortisone injections are contraindicated due to the patient’s allergy. This patient’s clinical picture is complicated by multiple comorbidities, that appears to be the primary etiology for the multiple joint issues and pain.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving foot pain, then check the rights and deadlines that apply to your plan.