Pes Planus denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: This is a female that was seen by podiatry and diagnosed with posterior tibial tendonitis and pes planus (fallen arches) to both feet. The examination reports moderate loss of foot arch with a medical shift bilaterally and tenderness to the posterior tibial tendons bilaterally. She reports that her foot pain is relieved with rest and orthotics, and that her orthotics are broken down. Podiatry recommends new functional orthotics to control the potential collapse secondary to her pes valgus deformity. At issue is whether the custom molded orthopedic shoe inserts are medically necessary to treat the patient’s medical condition.

Nature of Statutory Criteria/Case Summary: The patient had been diagnosed with pes planus. The provider noted a diagnosis of patellofemoral pain syndrome of both knees. The patient was noted to have recovered from bilateral talar contusions. The provider noted that the patient was able to resume physical education activities, although she had been avoiding high impact sporting activities. The patient reported fatigue in her calves and inability to tolerate dress shoes for prolonged periods of time, as over-the-counter orthotics do not fit. Physical examination findings included bilateral gastrocnemius equinus and severe bilateral pes planus. In the independent medical review (IMR) application, the parent noted that the patient had tried and failed over-the-counter orthotics. The patient’s parent has requested authorization and coverage for bilateral custom foot orthotics (HCPCS L3020).

Where the denial was upheld

Findings: The physician reviewer found that the patient has requested authorization and coverage for bilateral custom foot orthotics (L3030). Experts advise that orthotics provide support to certain areas of the feet, correcting biomechanical abnormalities that lead to foot pain. Orthotics are recommended for the treatment of plantar fasciitis, specific joint arthritides of the feet, and various foot soft tissue abnormalities that may be caused by abnormal foot biomechanics. As stated in the citations below, orthotics can correct certain lower extremity biomechanical abnormalities that can lead to foot pain. The medical documentation supports that this patient presented to their physician with a chief complaint of bilateral flat foot left greater than right. The patient presents with lower back pain.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom orthotics. Findings: The physician reviewer found that initial use of basic pre-fabricated orthoses or inserts is recommended during acute phases, but with diverse anatomical differences, some patients may subsequently require a custom made orthosis. The medical literature concludes there is no high-level evidence supporting the use of foot orthoses for flexible pes planus. Per the authors, “there is good to moderate level evidence that foot orthoses improve physical function (medial-lateral sway in standing (level II) and energy cost during walking (level III)). There is low level evidence (level IV) that foot orthoses improve pain, reduce rearfoot eversion, alter loading and impact forces; and reduce rearfoot inversion and eversion moments in flexible pes planus.

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 pes planus, then check the rights and deadlines that apply to your plan.