Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 48-year-old woman with severe pain in her feet. She has been diagnosed with chronic plantar fasciitis. She has been treated with medication, therapy and injections but continues to have pain. Her provider has recommended extracorporeal shock wave therapy (ESWT), which has been denied by the Health Plan on the basis that it is considered investigational.ESWT has been reported to be successful for chronic plantar fasciitis. It is not experimental. The technology utilized during the procedure has been approved by the Food and Drug Administration. The patient has failed all conservative modalities. Her only remaining treatment options are to live with the pain, surgery or ESWT. ESWT is less invasive than surgery; as such, it is appropriate for the patient to undergo a trial of ESWT prior to open surgical repair. Accordingly, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 48-year-old female who has requested authorization for extracorporeal shock wave therapy (ESWT) for the treatment of chronic plantar fasciitis. Review of the submitted documentation indicates the patient has a history of heel pain lasting more than a year. She has failed conservative therapy including steroid injections and physical therapy. The patient wishes to proceed with ESWT as recommended by her provider. The Health Plan has denied authorization for ESWT on the basis that it has not been established as efficacious for treatment of the patients condition.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 doubt regarding the efficacy of ESWT. At this time, there is insufficient evidence demonstrating 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 procedure 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 48-year-old female with a history of chronic plantar fasciitis. She has been treated in the past with orthotics, strappings, NSAIDs, immobilization and cortisone injections. None of these treatment modalities have alleviated the patients pain. The patient is now seeking authorization for extracorporeal shock wave therapy (ESWT). The Health Plan has denied coverage for ESWT on the basis that it is considered investigational for treatment of plantar fasciitis.The current scientific literature provides no evidence that ESWT for treatment of plantar fasciitis is more effective than minimally invasive surgical treatment or current conservative treatment. Available studies demonstrate about an 80% effective rate for ESWT. Endoscopic and open plantar fasciotomies demonstrate a 90% effective rate. Thus, ESWT is not likely to be more effective for treatment of the patients pain than open or endoscopic plantar fasciotomies. Accordingly, 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.