Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plantar Fascial Fibromatosis and Flat Feet
Treatment: Foot Insert (L3000)
The insurer denied: Foot Insert (L3000)
The denial is upheld.

The patient is a young adult female who is diagnosed with planter fasciitis of the left foot, flat foot right foot, flat foot left foot, pain in the right ankle joint of the right foot, and posterior tibial tendon dysfunction left foot. Subjective findings state that the patient presents with a chief complaint of painful flatfoot right foot and painful flatfoot left foot, and which are painful on ambulation, and which are painful with weight bearing. The patient's pain is inside part of the right foot, there is pain on the inside part of the left foot. Pain is worse with activity and better with rest. Symptoms have been going for about three months. There is no history of clinical findings in the medical history. The patient's medications included Cefadroxil, ZeasorbAF, Formadon, Loprox, and Terbinifine. The patient's social history was significant for nonsmoker, denies drug use, and denies alcohol. The patient's physical examination (PE) was significant for antalgic gait due to pain, limp left secondary due to biomechanical compensation for functional limb length discrepancy, pes planus with pronation bilateral left greater the right, plantar fasciitis left foot, posterior tibial tendon dysfunction left foot and excessive pronatory gait and unstable gait. The Plan was for a duration of treatment for
three months. The patient had Achilles' tendon stretching. However, ankle support failed, over the counter arch supports for three months failed, nonsteroidal anti-inflammatory drugs (NSAIDS) failed, and physical therapy failed. It is stated that custom orthotics should prevent posterior tibial tendon tear in the future.
The previous denial was based on medical necessity not being met based on criteria provided.

The proposed treatment was not medically necessary.

In the documentation, the criteria from the denial are listed.
After careful review of the records, a clear rationale is not provided to support the approval. For approval of this request, a clear rationale as to why custom inserts would benefit the patient needs to be provided/supported. In the documentation provided all measures are stated that have failed, including over the counter inserts, ankle braces, physical therapy, and nonsteroidal anti-inflammatory drugs (NSAIDS). The documentation states that the patient has been suffering for three months. However, three months is a short period of time to exhaust all the provided treatment measures. In addition, as over the counter inserts have not worked, rationale behind custom inserts needs to be provided. In addition, there is no mention of in office taping/strapping that may indicate the need for custom inserts.
In the three months the patient has been having pain, sufficient time has not been given to exhaust other treatment measures. In addition, knowing that the over-the-counter inserts did not help, there is no supporting documentation that custom orthotics would benefit.
The decision is to uphold the denial based on clinical judgment. In addition, the Centers for Medicare and Medicaid Services (CMS) guidelines require a clear medical need, which is not supported in the enclosed medial documentation.