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

Physician 1: The patient is a 62-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 night splints, orthopedic shoes, steroid injections, and NSAIDs. 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.Physician 2: In October 2005 the patients provider reported she has been suffering with chronic foot and heel pain. Physical examination revealed hallux limitations and palpable heel pain, especially at the origin of the plantar fascia. There were no significant x-ray findings noted. Treatment with a plantar fascia night splint was indicated. No further progress notes are enclosed, however, a medical history showed that she has been treated with cortisone injection and NSAIDs. A night splint and orthopedic shoes were also tried. No relief of heel pain was noted. The patients physician is now recommending extracorporeal shock wave therapy (ESWT) for treatment of her chronic maximal plantar fasciitis. The Health Plan has denied coverage for ESWT indicating it 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%). Also, it does not appear that this patient has tried custom triplanar orthotics, which have a very good efficacy rate for treatment of fasciitis. As 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.Physician 3: The patient is a 62-year-old woman with long-standing plantar fasciitis. She has tried splints, shoes, medications, and injections and she still has pain. The patient and her provider have requested authorization and coverage for extracorporeal shock wave therapy (ESWT). The Health Plan has denied authorization for ESWT indicating there is insufficient scientific data supporting its efficacy.ESWT is an approved procedure, which has had success in relieving pain. There are few risks involved, and the benefits include avoidance of open surgery. In this case, the patients pain is significant, and she has failed conservative treatment. Thus, a trial of ESWT is medically reasonable and appropriate prior to proceeding with surgical release of the plantar fascia. Based upon the information set forth above, I have determined that the requested therapy 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.