Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hallux Rigidus.
Treatment:  Podiatry Services (treatment of Hallux Rigidus).

The insurer denied coverage for Podiatry Services (treatment of Hallux Rigidus).  The denial is overturned. 

This is a female patient, who presented to a podiatrist for follow up of right great toe and 5th toe pain.  She reported continued pain and difficulty walking despite previous conservative treatment of a steroid injection, anti-inflammatories, padding, topical medications, and shoe gear modifications.  She stated her job was threatening termination if her gait issues continued.  Her pain was rated at an 8/10, and she stated interest in pursuing surgical intervention.  Diagnoses of right foot pain, degenerative arthritis secondary to hallux limitus, and hammertoe were rendered. 

The insurer indicated that at the time of the denial there were no imaging reports available to document the pathology to the great toe.  However, the presented clinical information does reveal an imaging report, as well as copies of the actual radiographic images, which clearly detail the pathology at the great toe joint.  Thus, the available data do support the planned procedures.  Thus, the insurer initially acted reasonably with sound medical judgment, but subsequent records have reversed that action.  It is in the patient's best interest to proceed with the surgery.   

"If operative treatment is opted for grade 3 and 4 osteoarthritis of the first metatarsophalangeal joint, arthrodesis is considered the standard of care.  However, if preservation of joint mobility is preferred, implant arthroplasty could be favored.  Previous studies have suggested hemiarthroplasty might result in less pain, better function, and greater patient satisfaction compared with arthrodesis.  However, these studies only evaluated short-term results (range 2.2 to 6.6 years).  The aim of our study was to determine whether patients treated with hemiarthroplasty would show better postoperative outcomes compared with those treated with arthrodesis after 5 years after surgery.  The American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal interphalangeal (AOFAS-HMI) scale score was used as the primary outcome measure" (Beekhuizen, S. R. et al.). 

"Hallux rigidus, Latin for Stiff Toe, is characterized by an osteoarthritic degeneration of the articular surfaces of the first metatarsophalangeal joint...A comprehensive literature search using PubMed database has been performed, up to April 1, 2017.  Several different types of treatment are described in the literature for low-grade hallux rigidus.  The management for hallux rigidus can involve a variety of therapeutic interventions, conservative or operative.  Hallux rigidus is a complex disease characterized by several clinical and pathological findings, and to achieve optimal results, surgical treatment for low-grade forms should be chosen between several surgical techniques depending on the degree of arthritis and other different clinical conditions" (Caravelli, S. et al.).

The patient has experienced chronic right 1st and 5th toe pain.  The 5th toe hammertoe correction was previously approved by the health plan.  The claimant's great toe pain has not responded to conservative therapies.  She has difficulty walking and pain due to the condition.  There is noted pain with joint range of motion on examination.  Radiographic findings are consistent with advanced arthritic changes to the joint.  Given the failure of conservative modalities, surgical intervention is indicated in the form of an implant hemiarthroplasty which has proven evidenced based results. 

The medical necessity for Podiatry Services (treatment of Hallux Rigidus) is substantiated.  The insurer's denial is overturned.