Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for custom fit dynamic response ankle foot orthosis for his post-traumatic arthritis of the right ankle and foot.  The enrollee has chronic, long-standing ankle discomfort from post-traumatic arthritis. He has a history of an accident resulting in bilateral distal tibial/fibular fractures, which required plating medially and laterally in both ankles. The right subsequently required removal of some loose screws, as well as hip bone grafting with external fixation for a non-union. At an orthopedic surgery visit for bilateral ankle pain, the enrollee had limited ankle movements, right more than the left, but had decent gait on physical exam. Upon the enrollees request for non-surgical options for his condition, his physician submitted the paperwork for an orthosis, and referred the enrollee for a consult. The enrollee had two surgeries to his right ankle and one surgery to his left ankle. He reported localized pain to the medial and lateral ankle; symptoms were mild to severe in nature, present both with activity (i.e. standing and walking) and at rest, and relieved with ibuprofen. He also reported limited walking tolerance associated with swelling and pain. On physical exam, the enrollee had full range of motion, full strength, and normal neurologic testing at the ankles. He has antalgic gait, and x-ray findings showed severe end-stage post-traumatic ankle arthritis of both ankles, right more than the left. His physician indicated the enrollee has a clear indication for use of the external prosthetic, and this would be an appropriate treatment prior to surgical intervention. According to the medical literature, AFO use is effective for enrollees with flaccid ankle muscle paresis, (i.e., muscle weakness) to prevent foot drop and muscle contractures; and enrollees with spastic paresis, (i.e., uncontrollable movements) to help stand (posture) and walk without falling. Current research supports the AFO for medical conditions, such as Duchenne muscular dystrophy, post-stroke, and cerebral palsy, respectively. Based on the record, the enrollees condition of ankle pain does not meet the literature recommendations for AFO use. On both orthopedic surgeons notes, the enrollee was able to ambulate without assistance, there was no indication of foot drop at the ankle, and enrollee had full range of motion, normal strength and neurologic findings. He had no indication of muscle weakness or spastic movements at both ankles. With the negative history and physical exam findings, the enrollees post-traumatic arthritis of the right ankle and foot diagnosis do not meet the current medical literature support for AFO use.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is a board certified orthopedic surgery and sports medicine, 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 similar medical condition.