Appeal type: Medical necessity
Decision: Overturned

Diagnosis: plantar fasciitis

Treatment: Durable Medical Equipment (Shoe Insert - L3000)

The insurer denied coverage for Durable Medical Equipment (Shoe Insert - L3000)

The denial is overturned
 

This case involves an adult male diagnosed with plantar fasciitis under review for custom fabricated orthotics. The patient was evaluated for orthotics. The diagnoses were bilateral plantar fasciitis; tibialis posterior tendinopathy; ligamental laxity. The patient reported pain while walking and standing. The patient was prescribed custom foot orthotics toe heel cup, medial arch support, first ray cut out. The patient presented for new orthotics. He reported chronic pain in his feet without his orthotics. The examination of the foot included heel pain right and left on palpation to plantar fascia with no defects palpable. The encounter diagnoses included pes planus, plantarflexion bilaterally and other hammertoe of the right and left foot.

The Plan denied coverage for Durable Medical Equipment (Shoe Insert - L3000 based service is not medically necessary according to the MCG  Criteria from for Foot Orthotics, Custom." Reference called Milliman Care Guidelines (MCG) (27th edition). 

The appeal letter noted that the patient has a diagnosis of plantar fasciitis and has been in pain for over three months, the patient has tried over the counter (OTC) inserts modified activities, stretching with no relief. The patient has been wearing L3000 orthotics, that are worn out and causing pain.   

Based on the documentation the patient has been treated with custom orthotics for several years and has failed conservative treatment to include OTC prefabricated inserts  without relief. The patient meets the criteria for approval according to the Milliman Care Guidelines (MCG) (27th edition): Foot Orthotics, Custom. 

Per the cited references, orthotics are an effective tool in treating plantar fasciitis. Patients looking to use orthotics for plantar fasciitis may select orthotic type based on preference and available resources. The patient has failed OTC inserts and standard conservative care and his current custom orthic are worn and causes pain.   

Per the MCG) (27th edition): Foot Orthotics, Custom, the clinical Indication for custom foot orthotics may be indicated when Arch, heel, or other foot pain; Foot condition, plantar fasciitis, with ALL of the following: Adjustment of activities failed to improve symptoms; Anti-inflammatory medications failed to improve symptoms; Prefabricated orthotics failed to improve symptoms; Stretching of calf muscles and plantar surface failed to improve symptoms; Symptoms are present for 1 month or more. 

Per the Official  Disability Guidelines(ODG),]the outcomes from custom orthoses, when indicated, are highly variable and somewhat dependent on fabricator skill and materials used. Initial use of basic pre-fabricated orthoses or inserts is recommended during acute phases, but with diverse anatomical differences some patients may subsequently require a custom-made orthosis. Plantar fasciitis/fasciosis: Recommended following failure of stretching and anti-inflammatories, using pre-fabricated orthoses initially. 

Based on the clinical documentation, the patient has had a diagnosis of plantar fasciitis for several years and  has failed conservative treatment to include OTC inserts modified activities, stretching with no relief. The patient has been wearing L3000 orthotics, that are worn out and causing pain. As such, the denial of coverage for Durable Medical Equipment (Shoe Insert - L3000) is overturned as medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Durable Medical Equipment (Shoe Insert - L3000) is substantiated.