Pes Planus Flat Feet denials in California external review

What the reviewers wrote

Where the denial was overturned

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).

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for custom orthotics for both feet. As discussed in the peer-reviewed medical literature, treatment with custom orthotics can help correct painful biomechanical abnormalities in the feet. Carr and colleagues noted that there is a lack of “large, prospective studies that compare the natural history of idiopathic, flexible flat feet throughout development in response to various treatments.” The authors found that, “Painful flexible flatfoot may benefit from orthopedic intervention, such as physical therapy, bracing, or even a surgical procedure.” This patient’s records document substantial bilateral leg and foot pain.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone. The Centers for Disease Control and Prevention (CDC) guidelines state that, “Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently.

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.

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 flat feet, then check the rights and deadlines that apply to your plan.