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

Physician 1: The patient is a 62-year-old female with a history of plantar fasciitis. She has attempted conservative treatments including medication, orthotics, and Botox injections without lasting benefit. The patient has requested authorization and coverage for extracorporeal shock wave therapy. The Health Plan has denied this request on the basis there is insufficient evidence showing the long-term safety and efficacy of extracorporeal shock wave therapy for treatment of plantar fasciitis. Extracorporeal shock wave therapy is not considered to be standard of care. To date, long-term prospective studies of the effectiveness of extracorporeal shock wave therapy have not been performed. The current scientific literature does not demonstrate the efficacy of the requested therapy or the associated complications or risks. Therefore, the patient should be treated with standard of care modalities. 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. Therefore, the Health Plans denial should be upheld.Physician 2: Review of the submitted progress notes indicates the patient is a 62-year-old female who has suffered with painful left plantar fasciitis and has been treated with NSAIDS, orthotics, cortisone injections, splints, strappings and Botox injections. Unfortunately, standard treatment modalities have not alleviated the patients foot pain. The patients provider has recommended extracorporeal shock wave therapy (ESWT) for treatment of her plantar fasciitis. The Health Plan has denied authorization for the proposed therapy indicating it is considered experimental.ESWT for the treatment of plantar fasciitis was approved by the Food and Drug Administration in 2000. There have been numerous articles regarding ESWT; the efficacy of the therapy ranges from 40% to 80%. Endoscopic plantar fasciotomy and open plantar fasciotomy, while carrying the usual risks associated with surgery, demonstrate an 85% to 90% cure rate. Based upon clinical experience as well as the published effective cure rates, 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. Therefore, the Health Plans denial should be upheld.Physician 3: The patient is a 62-year-old female with a history of chronic plantar fasciitis. She has failed several treatments including medications, orthotics, and injections. The patient does not want to undergo surgery. She has requested authorization and coverage for extracorporeal shock wave therapy (ESWT).  The Health Plan has denied the request indicating there is insufficient evidence demonstrating the long-term safety and efficacy of ESWT in the treatment of plantar fasciitis.Review of the relevant 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 insufficient 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. A recent randomized, placebo-controlled, double blind, clinical trial yielded results that contradicted the favorable findings of previous studies, thus raising doubts regarding the efficacy of ESWT for some patients with plantar fasciitis. 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. Therefore, the Health Plans denial should be upheld.