Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Foot Bunion Deformity
Treatment: Current Procedural Terminology (CPT) code L3000 x 2 (right/left) (custom made orthotics shoe inserts)
The insurer denied coverage for Current Procedural Terminology code L3000 x 2 (right/left) (custom made orthotics shoe inserts)
The denial is upheld

The patient presented to the doctor's office for a painful left foot bunion deformity. Neutral position custom orthoses were dispensed and the patient was advised on a break in period. The patient was instructed to notify the treating provider of any irritation from the orthoses.

The insurer denied coverage of the prescribed orthoses. 

Becker, B.A. et al. (2018), "Most foot disorders do not require podiatry referral or complex interventions. After the clinical diagnosis is made, these conditions can typically be managed with over-the-counter (OTC) and home remedies, with guidance from the primary care physician. Stretching and strengthening exercises, along with the use of heel cups, resolve most plantar fasciitis cases and are at least as effective as nonsteroidal anti-inflammatory drugs or steroid injections. Hallux rigidus is best managed with a hard-soled shoe or rigid insert that relieves pain by restricting motion across the metatarsophalangeal joint."

Kuhn, J., and Alvi, F. (2021), "Treatment of patients with HV [hallux valgus] deformity revolves around non-surgical and surgical treatments. Usually, non-surgical treatments are trialed first. If there is treatment failure, surgical repair should be considered. Interestingly, there is no definitive evidence that conservative treatment is effective. However, the American College of Foot and Ankle Surgeons still recommends the use of conservative therapy before perusing a surgical solution. It is essential for patients to trial wide shoes and orthotics before considering more invasive options.  The goal of conservative treatment is to manage the symptoms. It does not correct the actual deformity. Non-surgical treatments options include:

1)	Shoe modification: Low-heeled, wide shoes.
2)	Orthoses: Improves alignment and support.
3)	Analgesics: Acetaminophen and NSAIDs.
4)	Ice: Icing the inflamed deformity to reduce inflammation.
5)	Medial bunion pads: Prevents irritation of HV deformity.
6)	Stretching: Helps maintain joint mobility in the affected joint."

Doty, J. F., Alvarez, R. G., Ervin, T. B., Heard, A., Gilbreath, J., & Richardson, N. S. (2015), "The purpose of the present study was to compare the hallux valgus deformity pressure parameters seen in standard footwear (no orthosis) versus the pressure observed in the same footwear with the addition of 3 different length orthoses. The forefoot pressure at a hallux valgus deformity was recorded with pressure sensors placed on the plantar, medial, and dorsal surface of the first metatarsal head. The participants performed walking trials without an orthosis and with orthoses of 3 different lengths. The average pressure and maximum pressure of each area was recorded for each orthosis, and comparisons were made across the groups. The plantar pressures were decreased in the full length and 3/4 length orthoses, and the dorsal pressures were increased with the use of the full-length and sulcus-length orthoses. Significant changes in medial pressure were not seen with the addition of any orthosis compared with standard footwear alone. However, a trend toward increased medial pressures was seen with the full- and sulcus-length orthoses, and the 3/4-length orthoses exhibited a trend toward decreased medial pressures. We were unable to demonstrate that the use of a custom foot orthosis significantly decreases the medial pressures on the first metatarsal head in patients with hallux valgus deformity."                                                         

The patient is noted to have a left bunion deformity. There is no information on the impact of the condition on the patient's activities or any description of prior treatments. The record does not indicate that over the counter devices were attempted prior to custom devices.      

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Custom orthoses are not standard first line therapies for bunion deformities.

The insurer's denial of coverage for the CPT code L3000 x 2 (right/left) is upheld. Medical Necessity is not substantiated.