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

Physician 1:  The patient is a 36-year-old female with a documented history of plantar fasciitis. Her provider indicates the patient has tried multiple conservative treatment attempts including corticosteroid injections without success. She underwent extracorporeal shock wave therapy (ESWT) on the left heel with good results. She has now requested authorization and coverage for ESWT to the right heel. The Health Plan has denied authorization for the proposed procedure on the basis that it is considered investigational.There is sufficient literature to support the use of ESWT for chronic plantar fasciitis. The above referenced meta-analysis by Sems, et. al. suggests that ESWT has a role in treating chronic plantar fasciitis and can be effective when used properly. This patient has already tried and failed injection therapy. Furthermore, the patients left foot was treated successfully with ESWT. 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 36-year-old female with a history of heel pain. In 2003 the patient underwent extracorporeal shock wave therapy (ESWT) to her left foot for painful plantar fasciitis. According to the submitted notes, the procedure was successful. In November 2005 the patient presented to her podiatrist with complaints of right heel pain. Treatment for plantar fasciitis was initiated. Between November 2005 and March 2006 the patient was treated with NSAIDs, orthotics, night splint, home physical therapy and cortisone injections. These treatments failed to alleviate her right heel pain. A request for ESWT to her right heel was initiated. The Health Plan denied this request stating the requested procedure is investigational.ESWT is an FDA approved treatment modality for chronic proximal plantar fasciitis. However, current scientific literature provides no evidence that ESWT for treatment of plantar fasciitis is more effective than current conservative treatment or minimally invasive surgical treatment. Endoscopic plantar fasciotomy demonstrates about a 90% cure rate, which exceeds the cure rate of ESWT (70-80%). Accordingly, 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.Physician 3:  The patient is a 36-year-old female who has requested authorization and coverage for extracorporeal shock wave therapy (ESWT) for the treatment of chronic heel pain (plantar fasciitis). The patient has failed multiple standard therapies including orthotics, steroid injections, and weight loss. The Health Plan has denied authorization for ESWT indicating the procedure is considered investigational.Review of the 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. Recent randomized, placebo-controlled, double-blind, clinical trials yielded results that contradicted the positive findings of the previous studies, thereby raising doubts regarding the efficacy of ESWT for some patients with plantar fasciitis. At this time there is nothing to indicate that the requested ESWT is likely to be more beneficial for this patient than any available standard therapy.Based upon the information set forth above, I have determined that the requested therapy 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.