Custom Orthotics denials in California external review

What the reviewers wrote

Where the denial was overturned

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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom orthotics. The nationally-recognized, evidence-based Official Disability Guidelines (ODG) state that both prefabricated and custom orthotic devices are recommended for plantar fasciitis. Wrobel and colleagues conducted a randomized, controlled trial of custom foot orthoses for the treatment of plantar heel pain. They concluded that custom foot orthoses demonstrated 5.6-fold greater improvements in spontaneous physical activity versus pre-fabricated orthoses or sham insole treatment for plantar fasciitis.

Where the denial was upheld

A male enrollee with a diagnosis of plantar fasciitis and hypertension. An examination dated reported that the patient complained of pain to the second and third toes and the right foot when walking. The patient is noted to be using orthotics currently as well as ice as needed for pain. The patient’s plantar fascia is noted to be stable according to the examination. There was no physical exam of the foot during the office visit. X-rays of right foot that were taken revealed no fracture or joint space abnormality. The soft tissues are normal. The patient has used orthotics for roughly six years according to a note written by the patient. He advised that for six years he has received new orthotics for plantar fasciitis, which inhibited his normal comfortable ambulation. It has been recommended that patient obtain a new pair of custom orthotics.

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