Custom Foot Orthotics 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: The patient requested reimbursement for orthotics for the left and right foot provided on 12/12/22.The presentation of pes planovalgus deformity includes a decrease in the medial longitudinal arch with the rearfoot in valgus and the forefoot in abduction. Initially, the presentation may be asymptomatic but can progress to a significant source of pain in the heel, midfoot, calf, knee, lower back, and hip, and may result in increased deformity, loss of function, and abnormal gait. Treatment consists of both conservative and surgical management. Conservative treatment modalities include physical therapy or treatment with foot orthotics. Surgical treatment is used in those patients who failed conservative management and in those with fixed deformities.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for custom foot orthotics. In this case, the records submitted for review demonstrate that the patient is an avid athlete and is experiencing knee, ankle, and foot pain. The records show that the patient has a leg length discrepancy with excessive foot pronation bilaterally and has a history of Sever’s apophysitis. The patient is noted to have right foot and ankle pain which is exacerbated with activity. Biomechanical changes in the foot and ankle, such as pronation, abducted gait, and limb length discrepancy can place excessive pressure on certain muscles, tendons, and ligaments, which may cause inflammation and pain. This pain can alter gait which can lead to foot and ankle pain.

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.

The enrollee is requesting authorization and coverage for custom foot orthotics. The enrollee has plantar fascial fibromatosis. She also has left heel pain that has been unresponsive to anti-inflammatories, pain medications, shoe modification, over-the-counter orthotics, stretching, and ice. She reported her pain as throbbing and reported she was unable to walk. Her podiatrist recommended physical therapy and custom orthotics. This enrollee’s records show a three-month history of heel pain, and records support the enrollee experienced a similar issue in the past, which responded only to an injection. Medical records do not show the enrollee was offered a steroid injection. Although prescribed, the records do not support the enrollee completed a course of physical therapy. There is no evidence of a follow up with the provider to assess the enrollee’s response to the treatment plan.

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 Custom Foot Orthotics, then check the rights and deadlines that apply to your plan.