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

Physician 1The patient is a 55-year-old woman who is requesting extracorporeal shockwave therapy for treatment of plantar fasciitis. The Health Plan has denied her 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, 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 2The patient is a 55-year-old woman who 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 therapy is considered investigational treatment for the patients condition. Review of the submitted documentation indicates the patient has tried conservative treatment including orthotics, local steroid injections, and oral NSAIDS. The patient wishes to receive ESWT as an alternative to surgery since her pain has not resolved.Although there is some evidence that ESWT can provide a realistic degree of pain relief with chronic plantar fasciitis, 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 ESWT or any adverse effects it may cause. In addition, 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 extracorporeal shockwave therapy 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 3The patient is a 55-year-old woman with a history of heel pain. The submitted records provide no evidence of trauma. The patient has undergone numerous treatments, including local steroid injections to painful heels, physical therapy, NSAIDS, and custom orthotics. The patients pain has not resolved. A request has been made for extracorporeal shockwave therapy (ESWT). The Health Plan indicates ESWT is considered investigational.The 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. The next treatment step for this patient would be plantar fascia right splint or endoscopic plantar fasciotomy. The endoscopic plantar fasciotomy demonstrates about a 90% cure rate, which exceeds the cure rate of ESWT (65-70%). This patient demonstrates no comorbidities, which would put her at a greater risk for surgery. 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.