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.

Nature of Statutory Criteria/ Case Summary: This is a female that was seen by podiatry and diagnosed with posterior tibial tendonitis and pes planus (fallen arches) to both feet. The examination reports moderate loss of foot arch with a medical shift bilaterally and tenderness to the posterior tibial tendons bilaterally. She reports that her foot pain is relieved with rest and orthotics, and that her orthotics are broken down. Podiatry recommends new functional orthotics to control the potential collapse secondary to her pes valgus deformity. At issue is whether the custom molded orthopedic shoe inserts are medically necessary to treat the patient’s medical condition.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom myoelectric elbow-wrist-hand-finger orthosis (MyoPro 2 Motion G). There is a lack of evidence in current medical literature supporting the use of the requested device in assisting a patient with weakness of an upper limb due to a cerebral event, such as a brain tumor, in regaining neurological or muscular strength or function, such as the innate ability to use the arm for functional tasks when the orthosis is removed. The requested device takes time and effort to don and doff, with assistance from others, and is not proven to help a user become more independent. It is not proven to be well-adapted to everyday usage in the community setting, and there are high rates of abandonment due to its poor efficiency.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a computerized knee ankle foot orthosis (HCPCS L2006).Findings: Two out of three physician reviewers found that a computerized knee ankle foot orthosis (HCPCS L2006) is not likely to be more beneficial for you than any available standard therapy.Deems-Dluhy and colleagues concluded, “The microprocessor swing and stance controlled knee-ankle-foot orthosis may contribute to improved quality of life and health status of patients with lower-extremity impairments by providing the ability to have better walking speed, endurance, and functional balance.” Pröbsting and colleagues concluded, “The microprocessor stance and swing control orthosis may facilitate an easier, more physiological, and safer execution of many activities of daily living compared to traditional leg orthosis technologies.” The…

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