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

Physician 1The patient is a 71-year-old female who has left ankle and heel spur in her right heel. The patient states she has experienced pain for two years, with constant pain during the day and experiences sharp pains at night. In addition, the patients provider indicates the patient has received conservative treatment with cortisone injections, orthotics, NSAIDs, physical therapy, and rest, none of which have provided relief. Her physician has recommended extracorporeal shockwave therapy (ESWT) for treatment of her medical condition. The Health Plan has denied this request indicating the requested procedure is considered experimental for treatment of heel pain.ESWT has been shown to be effective in the treatment of chronic plantar fasciitis. The patient has failed conservative treatment including physical therapy. In light of the failure of standard treatment modalities, ESWT is likely to result in a superior outcome to other available standard therapies and is medically indicated for treatment of this patients heel pain. 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 2A 71-year-old female with a two-year history of plantar fasciitis. The patient has failed conservative therapy consisting of local steroid injections, oral NSAIDs, physical therapy, orthotics, and rest. The patient has requested authorization and coverage for extracorporeal shockwave therapy (ESWT) for treatment of plantar fasciitis. The Health Plan has denied this request indicating the requested procedure is considered investigational for treatment of the patients condition.Review of the medical literature indicates 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 associated with ESWT. Furthermore, there have been some conflicting results among the randomized, controlled studies. A recent clinical trial yielded results that contradict the positive findings of previous studies, thus raising doubts regarding the efficacy of ESWT for some patients with plantar fasciitis. At this time there is insufficient evidence to indicate that the requested ESWT is likely to result in a better clinical outcome than standard therapies. Therefore, 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. As such, the Health Plans denial should be upheld. Physician 3A 71-year-old woman who has been treated for insertional Achilles tendonitis with retrocalcaneal exostosis. The patient underwent multiple treatment modalities including orthotics, NSAIDs, Lidoderm patches, and acupuncture without relief. The patients podiatrist has recommended extracorporeal shockwave therapy (ESWT) for treatment of the patients heel pain. The Health Plan has denied the recommended treatment on the basis it is considered investigational in this setting.While ESWT has been approved by the Food and Drug Administration for treatment of proximal plantar fasciitis and lateral epicondylitis, it has not yet been approved for insertional Achilles tendonitis and retrocalcaneal exostosis. There are little if any controlled studies evaluating the efficacy of ESWT treatment in Achilles tendonitis and retrocalcaneal exostosis. To date, there is not sufficient evidence that ESWT is more beneficial for treatment of the patients heel pain than standard therapy. Continued attempts at conservative therapy are likely to be more successful than ESWT.Based upon the information set forth above, 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.