Extracorporeal Shock Wave Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 51-year-old man with a documented history of plantar fasciitis. The patient is also a diabetic. His provider indicates the patient has tried multiple conservative treatment attempts including corticosteroid injections without success. The patient’s provider has recommended the patient undergo extracorporeal shock wave therapy (ESWT). The Health Plan has denied authorization for the proposed procedure on the basis that it is considered investigational.Review of the medical literature reveals there is sufficient Class I data supporting ESWT for the treatment of plantar fasciitis. The recent article by Kudo and colleagues clearly establishes the efficacy of the treatment. This is in addition to an article by Hyer, which demonstrates the clinical utility of ESWT in the treatment of plantar fasciitis.

Physician 1: The patient is a 64-year-old male with chronic plantar fasciitis. He has attempted medications, heel supports, injections, and surgery without benefit. He is now requesting extracorporeal shockwave therapy (ESWT). The Health Plan has denied his request on the basis that ESWT is considered investigational.Although the long-term efficacy of ESWT is not yet known on a prospective basis, there has been some success on a short-term basis. ESWT has lower risk and is not as invasive as repeat surgery would be for this patient. In this case, the patient has prolonged pain despite all available standard therapy.

Where the denial was upheld

Physician 1: The patient is a 41-year-old female who has a history of right knee pain dating back to 2002. She underwent debridement of the patellar tendon in August 2003 yet still continues to have pain. Her physician indicates additional surgery is not indicated. The patient’s physician has recommended extracorporeal shock wave therapy. The Health Plan has denied coverage for the proposed therapy on the basis it is considered experimental.The requested therapy is not the standard of care at this time. There have not been sufficient studies establishing the benefit, risks, and outcomes of extracorporeal shock wave therapy for treatment of patellar tendonitis. Furthermore, there is no class I peer-reviewed data to demonstrate extracorporeal shock wave therapy is better for long-term relief of patellar tendonitis than standard therapy.

Physician 1: The patient is a 56-year-old female who has a history of foot pain due to plantar fasciitis. She underwent bilateral bunionectomies in 1996 and has reactive arthritis. The patient’s physician indicates the patient has failed conservative therapies including immobilization, orthotics, and injections. The patient continues to have pain. Her physician has recommended extracorporeal shock wave therapy (ESWT) as opposed to open plantar fascia release to relieve her symptoms. The Health Plan has denied coverage for ESWT on the basis it is considered investigational.Extracorporeal shock wave therapy is not considered to be the standard of care. To date, long-term prospective studies of the effectiveness of extracorporeal shock wave therapy have not been performed.

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 Extracorporeal Shock Wave Therapy, then check the rights and deadlines that apply to your plan.