Shoe Inserts denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee has requested authorization and coverage for foot inserts (Foot, Insert, Removable, Molded to PT model, UCB Type, Berkley Shell – Code L3000). The health plan has denied this request as not medically necessary. A review of the records indicates the enrollee was seen for follow-up of long-term right foot pain. He reported that he had done well with orthoses, but he needed a new pair as the previous orthotics had worn out. The use of orthotics had helped him avoid surgery. Physical examination of the right foot demonstrated mild local edema to the plantar/central forefoot, mild tenderness of the second metatarsal head plantarly with direct pressure, flexor contractures of the second and third toes with medial deviation at the metacarpophalangeal (MP) joints, as well as dorsal subluxation of the second MP joint.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with left foot pain and hallux limitus. The patient reported left big toe pain. The physical examination revealed a dorsal exostosis with slight pain and crepitus with first metatarsophalangeal (MTP) joint range of motion. The patient has requested authorization and coverage for a custom left foot orthotic. The Health Plan denied the request and reported the requested equipment is not medically necessary for the treatment of this patient. At issue in this case is whether a custom left foot orthotic is medically necessary for the treatment of the patient’s medical condition. A study by researchers reported that patients utilizing an orthosis, “demonstrated increased ability of participants to bear weight on the arthritic hallux MTP joint and restoration of physiologic stance.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting reimbursement for foot orthotics. At a podiatry visit, the enrollee reported her problem started when she rolled her right ankle and broke her fifth metatarsal bone. The podiatry assessment indicates chronic right ankle instability secondary to malunion fracture of the fifth metatarsal, creating right foot varus, peroneal tendinopathy right, peroneal tubercle exostosis right calcaneus, pes cavus, and bilateral hammertoe deformity. The podiatrist indicated because of the varus position of her right foot, the enrollee will chronically have ankle instability; her lateral ankle ligaments are extremely dysfunctional and do not have the tension/ability to keep her ankle from rolling. This has caused her peroneal tendons to be overused and to develop cystic changes.

Nature of Statutory Criteria/Case Summary: The parent of a pre-adolescent enrollee has requested shoe inserts for treatment of the enrollee’s bilateral pes planus. Findings: The physician reviewer found that after a review of the medical literature on this issue, the requested custom made orthotics are not medically necessary. The patient has a congenital flatfoot condition that is symptomatic, causing her foot, leg, and hip discomfort, as well as problems with balance. Her BMI of 19.3, which classifies her as overweight as well. On examination by her podiatrist, she is also noted to have an equinus bilaterally, which often accompanies a flexible flatfoot in children and contributes to her painful symptoms.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Shoe Insertswhen you appeal: reviewers routinely find that denials like yours didn’t hold up.