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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for procedure code 64632, destruction by neurolytic agent, plantar common digital nerves for treatment of the enrollees neuroma of the third intermetatarsal space of the right foot. Findings:  The physician reviewer found that The patient reported that the intensity and frequency of the pain is much less since the last series of injections. According to the documentation, the patient was injected with .5 mL of 4% alcohol solution to the intermetatarsal nerve just proximal to the neuroma mass. The patient tolerated the injection with no apparent side effects. The patients diagnosis includes neuroma third intermetatarsal space right foot. The patient reported that therapy was well tolerated. The patient has requested reimbursement for the procedure code 64632, destruction by neurolytic agent, plantar common digital nerve. The Health Plan denied this request and reported that the services at issue were investigational for treatment of this patients medical condition.The enclosed documentation and the medical literature do not support the superiority of the services at issue in this clinical setting. Neuromas are common elements that are generally located on the foot in between metatarsal heads. Treatment procedures may include biomechanical offloading of the neuroma site with an orthotic and a metatarsal and/or neuroma pad. Further treatments include one, two, or three local steroid injections to symptomatic area. Also noted is wider shoe gear and comfortable cushion shoe gear. These treatments have been studied and are noted to demonstrate very good results. If they do not alleviate a patients pain, it is recommended that the patient undergo excision of the neuroma. In this patients case, alcohol sclerosing agents used for the destruction of interdigital neuromas have not been proven more efficacious than standard treatments. Alcohol sclerosing agents are nonspecific ways to destroy the nerve and its efficacy is not well supported in the medical literature. Therefore, procedure code 64632, destruction by neurolytic agent, plantar common digital nerve was not likely to have been a superior treatment for this patients medical condition.  Final Result: All three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.