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

Physician 1: The patient is a 56-year-old man with a documented history of plantar fasciitis. His provider indicates multiple conservative attempts including corticosteroid injections were unsuccessful. The patients provider has recommended the patient undergo extracorporeal shock wave therapy (ESWT). The Health Plan has denied authorization for the proposed procedure on the basis that it is considered investigational.Review of the medical literature reveals there is sufficient Class I data supporting ESWT for the treatment of plantar fasciitis. Furthermore, this patient has had multiple previous attempts at conservative measures, which were unsuccessful. The patient is a good candidate for ESWT and there is adequate literature to support its use in this case. Therefore, I have determined that the requested procedure 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.Physician 2: The patient is a 56-year-old man with chronic heel pain. He received a prolonged course of conservative treatment, which failed to alleviate his pain. Prior to pursuing surgical treatment, his provider has recommended extracorporeal shock wave therapy (ESWT). The Health Plan has determined ESWT is considered investigational and therefore has denied coverage for the procedure.Review of the medical literature reveals a prospective study in the Journal of Bone and Joint Surgery (2004) demonstrating successful results with ESWT. Furthermore, ESWT carries lower risk and is not as invasive as surgical intervention. In this case, the patient has had prolonged pain despite treatment with standard therapy. It is medically reasonable and appropriate to attempt ESWT in the hopes of avoiding surgical intervention. Therefore, I have determined that the requested procedure 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.Physician 3: The patient is a 56-year-old male with chronic heel pain. He has requested authorization for extracorporeal shock wave therapy (ESWT). Conservative therapies including local steroid injections have not been successful in relieving the patients pain. The Health Plan has denied authorization for ESWT on the basis that it is an investigational procedure.A review of the medical literature shows there is some evidence that ESWT can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed appropriate conservative therapy. However, 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 treatment effect or any long-term adverse effects of ESWT. In addition, there have been some conflicting results among the randomized controlled studies; a recent randomized, placebo-controlled, double-blind clinical trial yielded results that contradicted the positive findings of previous studies thus, raising doubts regarding the efficacy of ESWT for some patients with plantar fasciitis. At this time, there is insufficient evidence demonstrating that ESWT is likely to be superior to standard treatment modalities in this clinical setting. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.