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

Physician 1The patient is a 51-year-old man who has requested authorization and coverage for extracorporeal shockwave therapy (ESWT) for treatment of plantar fasciitis. Review of the submitted documentation indicates the patient has a history of chronic heel pain. The patients provider indicates the patient has failed to respond to conservative treatment measures including rest, stretching, exercises, physical therapy, and NSAIDs. The patients provider has recommended ESWT. The Health Plan has denied this request indicating the requested therapy is considered investigational treatment for the patients condition.Although there is some evidence that ESWT can provide some pain relief from chronic plantar fasciitis, optimal treatment parameters have not been established and patient selection criteria have not been adequately defined. Additionally, there is a lack of information regarding the durability of ESWT or any adverse effects it may cause. Furthermore, there have been some conflicting results among the randomized, controlled studies thereby raising doubts regarding the efficacy of ESWT. At this time, there is nothing to indicate that ESWT is likely to be more beneficial for the treatment of the patients condition than any conservative 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. Therefore, the Health Plans denial should be upheld.Physician 2The patient is a 51-year-old man who is requesting extracorporeal shockwave therapy for treatment of plantar fasciitis. The submitted records demonstrate the patient has chronic heel pain with a calcaneal spur. The Health Plan has denied the patients request on the basis that extracorporeal shockwave therapy is considered investigational.Extracorporeal shockwave therapy is not considered to be standard of care. To date, long-term prospective studies of the effectiveness of extracorporeal shockwave 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, extracorporeal shockwave therapy is not indicated for treatment of the patients condition.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 3The patient is a 51-year-old man with a history of painful (left) plantar fasciitis due to abnormal overpronation. The patient has been treated with local steroid injections, orthotics, strappings, and oral pain medications. The patients pain has not resolved. The patients provider has recommended extracorporeal shockwave therapy (ESWT) for treatment of the patients heel pain. The Health Plan has denied authorization and coverage for ESWT indicating that it is considered investigational.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. Scientific evidence demonstrates that ESWT carries a 45-60% effective rate. Surgical intervention demonstrates a 90% effective rate. Continued conservative care greater than six months in duration also carries a 90% effective rate. Therefore, there is no evidence that ESWT is likely to result in greater benefit than standard therapy.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.