Heel Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for shoe orthotics for treatment of the enrollee’s bilateral foot pain. Findings: The physician reviewer found that the submitted medical documentation noted that this patient has bilateral foot pain with diagnoses of posterior tibial tendinitis, peroneal tendinitis, sinus tarsitis, and questionable stress fracture of calcaneus. The use of custom orthotics is the standard of care for treatment of bilateral foot pain as experienced by this patent. Custom orthotics are used in podiatry frequently to correct the abnormal biomechanics of patient’s feet, thereby alleviating abnormal strains of tendons, muscles, and ligaments, such as in this case. The correction of the abnormal biomechanics subsequently alleviates patient’s pain.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for shoe inserts for her diagnosed plantar fasciitis. Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity for the requested equipment in this clinical setting. In this particular case, it is well documented that this patient has a diagnosis of painful heels with plantar fasciitis. The patient is noted to complain of painful heels with a past medical history of left heel fracture. It is standard of care to treat plantar fasciitis with conservative treatment options including stretching, icing, anti-inflammatory medicine, and custom functional orthotics. Custom functional orthotics have been standard of care treatment for plantar fasciitis for several years.

Where the denial was upheld

Physician 1The patient is a 71-year-old female who has left ankle and heel spur in her right heel. The patient states she has experienced pain for two years, with constant pain during the day and experiences sharp pains at night. In addition, the patient’s provider indicates the patient has received conservative treatment with cortisone injections, orthotics, NSAIDs, physical therapy, and rest, none of which have provided relief. Her physician has recommended extracorporeal shockwave therapy (ESWT) for treatment of her medical condition. The Health Plan has denied this request indicating the requested procedure is considered experimental for treatment of heel pain.ESWT has been shown to be effective in the treatment of chronic plantar fasciitis. The patient has failed conservative treatment including physical therapy.

Physician 1The patient is a 51-year-old man who has requested authorization and coverage for extracorporeal shockwave therapy (ESWT) for treatment of plantar fasciitis. Review of the submitted documentation indicates the patient has a history of chronic heel pain. The patient’s provider indicates the patient has failed to respond to conservative treatment measures including rest, stretching, exercises, physical therapy, and NSAIDs. The patient’s provider has recommended ESWT. The Health Plan has denied this request indicating the requested therapy is considered investigational treatment for the patient’s condition.Although there is some evidence that ESWT can provide some pain relief from chronic plantar fasciitis, optimal treatment parameters have not been established and patient selection criteria have not been adequately defined.

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