Hallux Limitus: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with left foot pain and hallux limitus. The patient reported left big toe pain. The physical examination revealed a dorsal exostosis with slight pain and crepitus with first metatarsophalangeal (MTP) joint range of motion. The patient has requested authorization and coverage for a custom left foot orthotic. The Health Plan denied the request and reported the requested equipment is not medically necessary for the treatment of this patient. At issue in this case is whether a custom left foot orthotic is medically necessary for the treatment of the patient’s medical condition. A study by researchers reported that patients utilizing an orthosis, “demonstrated increased ability of participants to bear weight on the arthritic hallux MTP joint and restoration of physiologic stance.

Nature of Statutory Criteria/Case Summary: An enrollee has requested foot orthotics for treatment of the enrollee’s foot pain. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested foot orthotics. Custom foot orthotics are the standard of care for treatment of patients with over pronation, subtalar joint valgus, posterior tibial tendinopathy, hallux limitus, and heel pain. Custom foot orthotics are utilized to correct pathologic biomechanics of the foot, and in the case of this patient will correct his subtalar joint valgus, loss of medial column upon stance and reduce the dorsiflexion of the first metatarsal. In addition, custom foot orthotics have previously helped this patient and his current orthotics have lost their effectiveness to support his feet.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Cartiva joint arthroplasty, a synthetic cartilage implant, used during surgery. This patient presented to her provider with complaints of ongoing great toe pain. Per the provider’s notes, imaging revealed narrowing of the dorsal cartilage interval of the first metatarsophalangeal joint with associated osteophytes. The patient also developed secondary hallux valgus interphalangeus with the left big toe impinging on the second toe. The patient underwent placement of the Cartiva implant for treatment of great toe pain. The Cartiva implant utilized in this patient’s surgery is not supported by adequate data in the peer-reviewed medical literature when compared to cheilectomy or arthrodesis.

Nature of Statutory Criteria/Case Summary: A 46-year-old female enrollee has requested reimbursement for the graft procedure, Graffix Core for treatment of the enrollee’s hallux limitus, right foot. Findings: The physician reviewer found that It is well-established in the medical literature that the Grafix Core graft is effective for use in patients with non-healing diabetic foot ulcers. However, the medical literature does not support the use of the Grafix Core graft for application over denuded cartilage. Further studies must be performed to evaluate the efficacy of amniotic membrane and stem cell membranes over diseased cartilage.

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 hallux limitus was denied, the published record says the denial is worth fighting.