Appeal type: Medical necessity
Decision: Upheld

Diagnosis: plantar fasciitis

Treatment: Custom Shoe Insert (L3000 x 2)

The insurer denied coverage for Custom Shoe Insert (L3000 x 2)
 

The denial is upheld

 
This is a child who was seen by podiatry for an ingrown toenail. The patient has been diagnosed with plantar fasciitis. The patient has normal strength in his muscles. The patient had an orthotic in his shoes and has flat feet. The request is for Custom Shoe Inserts (L3000 x 2), which is under review.

There has been no trial of prefabricated devices. A trial of these devices would be warranted prior to custom devices, especially as the child will need new devices frequently as he grows.

The patient has not reported significant relief with the custom orthotic. At this point, a non-custom orthotic for medial arch support can be used.

"Although custom-made foot orthoses are generally considered the gold standard, the underlying mechanism is not well understood. Several studies found that custom-made orthoses were more effective than prefabricated orthoses for objective outcome measures through biomechanical assessments including dynamic balance, and pressure relief and load redistribution across plantar regions. However, a previous systematic review found no evidence that custom-made orthoses were more effective than prefabricated orthoses in the treatment of different types of foot pain. As custom-made orthoses are relatively more expensive than prefabricated orthoses, their clinical effectiveness needs to be evaluated." (Tran, K. & Spry, C. 2019).

Per Jafarnezhadgero, A., Madadi-Shad, M., Alavi-Mehr, S. M., & Granacher, U. (2018), "Due to inconclusive evidence on the effects of foot orthoses treatment on lower limb kinematics and kinetics in children, studies are needed that particularly evaluate the long-term use of foot orthoses on lower limb alignment during walking. Significant group by time interactions were observed during walking at preferred gait speed for maximum ankle eversion, maximum ankle internal rotation angle, minimum knee abduction angle, maximum knee abduction angle, maximum knee external rotation angle, maximum knee internal rotation angle, maximum hip extension angle, and maximum hip external rotation angle in favor of the foot orthoses group. In addition, statistically significant group by time interactions were detected for maximum posterior, and vertical ground reaction forces in favor of the foot orthoses group."

Conclusions: The long-term use of arch support foot orthoses proved to be feasible and effective in boys with flexible flat feet to improve lower limb alignment during walking."
Per Dars, S., Uden, H., Kumar, S., & Banwell, H. A. (2018), "Consensus and agreement was achieved for 83 statements directing the diagnosis of pes planus (using rearfoot measures), common signs and symptoms (e.g., pain, fatigue, abnormal gait and other functional concerns) that direct when to intervene into paediatric flexible pes planus. Prefabricated orthoses were the preferred intervention where adequate control is gained with their use."                                                         

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Durable Medical Equipment - Custom Shoe Inserts (L3000 x 2) is not substantiated.