Foot Toe 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: An enrollee has requested reimbursement for left foot hallux rigidus correction surgery (first metatarsophalangeal hemiarthroplasty utilizing Cartiva implant and dorsal cheilectomy). Current studies and literature comparing the use of the Cartiva implant to arthrodesis of the first MTP joint to treat hallux rigidus have mixed results in identifying a superior procedure. Most noted that additional studies with larger cohorts and longer follow-ups are needed to further access the ideal treatment. The records indicate that this patient was experiencing pain in the left first MTP joint which made walking and running painful. In addition, the patient’s job requires walking for most of the day. Per the provider, conservative treatment did not provide substantial pain relief.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Jublia 10% topical solution. Findings: The physician reviewer found that Onychomycosis is a fungal infection of the nail which can result in pain, disfigurement, and secondary infection. Ulcerations of the nail bed as well as resultant osteomyelitis of the underlying phalanges may result, particularly in patients with peripheral neuropathy. Onychomycosis can be caused by dermatophytes, yeasts or nondermatophyte molds. The most common dermatophyte organisms that cause onychomycosis are Trichophyton rubrum and Trichophyton mentagrophytes. Diagnosis is made by patient history, physical findings, and diagnostic testing. Onychomycosis can be treated by oral and topical antifungals. Oral medications have systemic risks and so are not appropriate for all patients.

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.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for acupuncture services. Although this patient reported that prior treatment with acupuncture has been beneficial in reducing symptoms, this is not documented in the records in terms of medication intake reduction, activities of daily living, improved range of motion, or with pre-acupuncture and post-acupuncture baselines for comparison purposes. After at least 14 prior acupuncture sessions were completed, the provider did not document any measurable, progressive, significant, objective functional improvement obtained with previous acupuncture to support an indication for the care rendered.

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 toe pain, then check the rights and deadlines that apply to your plan.