Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a 64-year-old male with chronic plantar fasciitis. He has attempted medications, heel supports, injections, and surgery without benefit. He is now requesting extracorporeal shockwave therapy (ESWT). The Health Plan has denied his request on the basis that ESWT is considered investigational.Although the long-term efficacy of ESWT is not yet known on a prospective basis, there has been some success on a short-term basis. ESWT has lower risk and is not as invasive as repeat surgery would be for this patient. In this case, the patient has prolonged pain despite all available standard therapy. Because the patient has exhausted available standard therapy and there is potential ESWT could benefit the patient, consideration of ESWT is reasonable in this specific case.Based upon the information set forth above, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Physician 2: The patient is a 64-year-old male with chronic plantar fasciitis. He has requested authorization for extracorporeal shockwave therapy (ESWT). A review of the documentation provided indicates the patient has experienced chronic heel pain for approximately one year. Various treatments including heel splints, orthotics, steroid injections, surgery, and physical therapy have failed. Therefore, the patients provider has requested authorization for ESWT.While review of the literature demonstrates there is some evidence ESWT can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed conservative therapy, optimal treatment parameters have not been established, patient selection criteria have not been adequately defined, and there is a lack of information regarding the durability of ESWT or any adverse effects it may cause. In addition, there have been some conflicting results among the randomized, controlled studies thereby raising doubts regarding the efficacy of ESWT. A recent randomized, placebo-controlled, double-blind, clinical trial yielded results that contradicted the positive findings of previous studies. At this time, there is nothing to indicate that ESWT is likely to be more beneficial for treatment of the patients condition than any conservative therapy. Therefore, the Health Plans denial should be upheld.Physician 3: The patient is a 64-year-old male who presented to his provider on 2/26/04 with complaints of left heel pain. Between 2/26/04 and 3/22/05, the patient has undergone multiple treatments for his diagnosis of plantar fasciitis. The patient has received physical therapy, orthotic therapy, night splint therapy, steroid injections, and endoscopic plantar fasciotomy. Despite these treatments, the patient continues to have pain. The patients provider has now recommended extracorporeal shockwave therapy (ESWT). The Health Plan has denied this request.The patient has had extensive and appropriate therapy without success. Remaining options for the patient include open release of plantar fascia with resection of calcaneal spur. This procedure carries significant risks. Although further study is required to determine the long-term effectiveness of ESWT, there is evidence that it has efficacy in the treatment of plantar fasciitis and carries fewer risks than open release surgery. This patient has exhausted standard therapy but for a surgery with significant risks. There is potential ESWT will benefit his condition. Therefore, I have determined the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.