Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plantar fascial fibromatosis; pes planus

Treatment: Custom Shoe Inserts L3000x2

The insurer denied coverage for Custom Shoe Inserts L3000x2. The denial reversed.

This patient is a male with a past medical history of multiple sclerosis (M.S.), plantar fascial fibromatosis, pes planus, degenerative joint disease (DJD) of the hip.  The prior treatments included massage therapy, rest/ice/compression/elevation (RICE), nonsteroidal anti-inflammatory drugs, changing of shoes, stretching/strengthening, and injection therapy. The office visit indicated the patient had worsening of his knee pain without custom functional foot orthosis (FFO) and he needed updated custom FFOs.  The notes indicated the patient had custom orthoses on and off since he was a child. The old orthoses were worn.  The patient had symptoms for over 6 months.  The patient had been on Cymbalta, Celebrex, and other oral nonsteroidal anti-inflammatory drugs with no relief.  The patient had injection therapy and still had heel pain.  
The patient had done stretching and range of motion.  The patient was using interferential stimulation and still had heel pain.  The provider discussed new FF oh to avoid foot surgery.  The patient was working full-time in-home care.  The diagnoses included peroneal tendinitis, right leg, plantar fascial fibromatosis, other congenital malformations of musculoskeletal system, hallux rigidus right foot, and left foot and other specified mononeuropathies of the bilateral lower limbs.  The patient underwent an injection into the right peroneal brevis tendon sheath and bilateral sural nerves for pain relief.  Physical therapy was recommended. The carrier denied the request, as there was no documentation the patient had tried over-the-counter shoe inserts.

The Letter of Medical Necessity indicated that biomechanical orthoses are devices used within the shoe.  They are designed to permit normal motion and to prevent abnormal motion and position of the foot.  The functional orthoses are not considered an arch support.  It does not support the arch of the foot, rather it moves the foot to normal position so that the foot provides its own stability.  It did not accommodate excessive pressure points on the foot, rather gravitational forces which passed through the foot were redirected and the areas of excessive pressure were eliminated because the bones of the foot were stable.  Functional orthoses are used to prevent the development of deformity when any abnormal function of the foot is recognized early.  It was further stated that these significantly alter the progression of many foot deformities.  The orthotic was not a brace.  The orthotics were custom molded foot inserts put into the patient's shoe, replacing the sole.

The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  This patient has MS with plantar fasciitis, pes planus and hip osteoarthritis and has been using custom orthoses (FFO) which have worn down.  Over the counter (OTC) orthotics would not adequately replace custom orthotics, especially in the case where a patient has been using custom FFOs. These are not simple arch supports, rather devices to support each individual foot and its biomechanical instabilities and malalignments.  OTC insoles are a substandard replacement for this patient, especially because they have used custom FFO prior to this. The custom shoe inserts L30002 are considered medically necessary for this patient.

The carrier's denial of coverage for Custom Shoe Inserts L3000x2 is reversed.  The medical necessity is substantiated.