Bunionectomy denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for right foot hallux valgus with bunionectomy, distal metatarsal osteotomy, and sesamoidectomy and reconstruction of the posterior tibial tendon with excision of accessory tarsal navicular bone. The medical documentation supports subjective complaints of pain to the medial aspect of the first metatarsal head with a bunion deformity, along with tenderness to the insertion of the posterior tibial tendons with a visible, palpable, and tender navicular accessory bone. Physical examination reveals a planus foot type with signs of gastrocnemius soleus equinus deformity bilaterally. Right medial arch region demonstrates tibialis posterior insertion with a large bony prominence with erythema, mild blistering, and tenderness to palpation.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bunion surgery for treatment of the enrollee’s bunion. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. Hallux valgus is a biomechanical malformation of a foot, causing strain and most often pain to the first metatarsophalangeal joint. This patient complains of painful first metatarsophalangeal joint unresponsive to conservative care including steroid injections to the metatarsophalangeal joint. She also relates a history of trauma which may exacerbate a bunion deformity. In this clinical setting, a bunionectomy for hallux valgus is standard of care and may be beneficial in alleviating the first metatarsophalangeal joint pain for the patient.

Where the denial was upheld

A 30-year-old female enrollee has requested bunionectomy procedures (28296 and 28310) and surgical shoes (L3260 x 2) for treatment of her bilateral hallux abductovalgus with bunion. Findings: The physician reviewer found that based on review of the available records, the patient has a bilateral moderate bunion deformity. Flex exam showed an increased intermetatarsal angle by 13 degrees, and a sesamoid position of 7 on the right, and 6 on the left. These radiographic findings are clinically consistent with the clinical findings of hallux abducto valgus. However, there is no documentation of failed conservative treatment options including alternative shoe gear, padding, anti-inflammatory treatments consisting of oral medications or local steroid injections, and orthotic therapy.

A 51-year-old female enrollee has requested a bunionectomy and surgical shoe for treatment of her hallux valgus deformity left foot. Findings: The physician reviewer found that based on review of the available records, the Academy of Ambulatory Foot and Ankle Surgery criteria for bunion surgery have not been met. Specifically, there is a lack of documentation that the patient’s bunion interferes with her ability to perform activities of daily living. Further, there is no documentation that her symptoms were not alleviated despite six months of conservative care including shoe gear modification, padding, inserts, injections, and medications. Moreover, the records do not indicate that patient meets the criteria of a bunion deformity with an intermetatarsal angle of greater than 15 degrees.

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