Metatarsalgia denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee has requested authorization and coverage for foot inserts (Foot, Insert, Removable, Molded to PT model, UCB Type, Berkley Shell – Code L3000). The health plan has denied this request as not medically necessary. A review of the records indicates the enrollee was seen for follow-up of long-term right foot pain. He reported that he had done well with orthoses, but he needed a new pair as the previous orthotics had worn out. The use of orthotics had helped him avoid surgery. Physical examination of the right foot demonstrated mild local edema to the plantar/central forefoot, mild tenderness of the second metatarsal head plantarly with direct pressure, flexor contractures of the second and third toes with medial deviation at the metacarpophalangeal (MP) joints, as well as dorsal subluxation of the second MP joint.

Findings: The physician reviewer found that The patient has requested authorization and coverage for custom bilateral foot orthotics for the stated condition of metatarsalgia and right plantar neuroma. The requested custom bilateral foot orthotics are medically reasonable and necessary to treat this patient’s medical condition based on the facts and relevant medical criteria. A review of the patient’s records provides sufficient evidence of a history of painful metatarsalgia and interdigital neuroma of the right lower limb. One study reports that custom orthotics are recommended for the treatment of patients with metatarsalgia and neuromas. Neuroma pads, metatarsal raised pads, and metatarsal bars are employed to allow custom orthotics to reduce patient’s foot pain.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the bilateral feet with contrast. The American College of Radiology (ACR) recommends an MRI of the foot without contrast for evaluation of chronic metatarsalgia with clinical concern for sesamoiditis, Morton’s neuroma, intermetatarsal bursitis, chronic plantar plate injury, or Freiberg’s infraction when radiographs are negative or equivocal. Santiago and colleagues reported, “In the appropriate clinical setting, administration of gadolinium contrast medium is not required for a reliable diagnosis of Morton’s neuroma.” In this case, the patient reported bilateral foot pain, reportedly refractory to prior treatment. Clinical examination findings reported a normal gait.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for shoe inserts (custom molded orthotics). The submitted documentation fails to demonstrate the medical necessity of the requested equipment. Walther and colleagues noted that supportive orthotics are superior to non-supportive orthotics regarding pain reduction in treatment of plantar fasciitis. This patient has been diagnosed with plantar fasciitis bilaterally, metatarsalgia bilaterally, pes planus foot structure with overpronation, and posterior tibial tendon dysfunction. Orthotics may be utilized to treat these ailments. However, the progress notes do not support the need for custom orthotics in this patient’s case, as there is no physical examination discussing type of heel pain, exact location of heel pain, or any forefoot 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 metatarsalgia, then check the rights and deadlines that apply to your plan.