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

Physician 1: The patient is a 41-year-old female who has a history of right knee pain dating back to 2002. She underwent debridement of the patellar tendon in August 2003 yet still continues to have pain. Her physician indicates additional surgery is not indicated. The patients physician has recommended extracorporeal shock wave therapy. The Health Plan has denied coverage for the proposed therapy on the basis it is considered experimental.The requested therapy is not the standard of care at this time. There have not been sufficient studies establishing the benefit, risks, and outcomes of extracorporeal shock wave therapy for treatment of patellar tendonitis. Furthermore, there is no class I peer-reviewed data to demonstrate extracorporeal shock wave therapy is better for long-term relief of patellar tendonitis than standard therapy. Therefore, 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: The patient is a 41-year-old woman who has apparently had a long history of patellar tendonitis dating to the fall of 2002. Her initial treatment included anti-inflammatory medications. Eventually, the patient underwent surgery and physical therapy. Her current treating physician recommends extracorporeal shock wave therapy (ESWT). The Health Plan has denied coverage for ESWT stating that it is investigational for treatment of patellar tendonitis.ESWT is a modality useful in treatment of plantar fasciitis. Several studies in progress also investigate the potential use of ESWT for treatment of medial and/or lateral epicondylitis. However, the current literature does not support the use of ESWT in the treatment of patellar tendonitis. Therefore, the patient should be treated with standard of care modalities. Accordingly, 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 41-year-old female who developed patellar tendonitis during the fall of 2002. Conservative treatment of her condition failed. An MRI then confirmed the presence of patellar tendonopathy. In August 2003, a surgical debridement of the patellar tendon was performed. Following this procedure the patient has experienced only partial improvement in her knee pain. She has been unable to pursue desired physical activities. Extracorporeal shock wave therapy (ESWT) has been recommended for her recalcitrant patellar tendonitis. At issue is whether ESWT is likely to be more beneficial for the patients condition than any standard available therapy.Over the past decade, ESWT has been reported as a non-invasive option for the treatment of some tendonopathies. This technology was derived from devices developed for urologic lithotripsy in the 1980s. Two forms of such shock wave therapy are currently available in the United States: electrohydraulic orthotripsy and electromagnetic orthotripsy. Each form of shock wave therapy is felt to act by using the energy of a shock wave to disrupt scar tissue. It is theorized that new blood vessel formation is thus facilitated and tendon healing thereby promoted. The technology at issue in this case is an example of an electrohydraulic or high-energy orthotripsy device.In October 2000, ESWT was approved by the FDA for treatment of plantar fasciitis. Since that time a number of prospective, randomized studies as well as meta-analyses have demonstrated that both low energy and high energy shock wave therapy devices are safe and potentially effective for the treatment of plantar fasciitis. However, as stated in the 2005 8th Edition of Orthopaedic Knowledge Update, whether extracorporeal shock wave therapy is effective for recalcitrant plantar fasciitis remains a controversial issue.Several studies have examined the effectiveness of ESWT in the treatment of lateral epicondylitis of the elbow and rotator cuff tendonitis of the shoulder. Conflicting results have been reported probably attributable to differences in study designs and application protocols. With respect to these elbow and shoulder conditions, the current recommendation is that ESWT be applied only in high quality clinical trials until it has been proven to be effective.An exhaustive review from 1997 through 2004 failed to produce any studies examining the role of ESWT in the treatment of patellar tendonitis of the knee. Based upon the lack of peer-reviewed data and conflicting reports in other tendon disorders, ESWT for patellar tendonitis is currently investigational and experimental. At the present time, ESWT has not been proven to be more beneficial for the treatment of recalcitrant patellar tendonitis than any available standard therapy. Therefore, 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.