Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 56-year-old female who has a history of foot pain due to plantar fasciitis. She underwent bilateral bunionectomies in 1996 and has reactive arthritis. The patients physician indicates the patient has failed conservative therapies including immobilization, orthotics, and injections. The patient continues to have pain. Her physician has recommended extracorporeal shock wave therapy (ESWT) as opposed to open plantar fascia release to relieve her symptoms. The Health Plan has denied coverage for ESWT on the basis it is considered investigational.Extracorporeal shock wave therapy is not considered to be the 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: The patient is a 56-year-old female who has requested authorization and coverage for extracorporeal shock wave therapy (ESWT). Review of the documentation provided indicates the patient has plantar fasciitis, which is limiting her activities. The patient has failed treatments consisting of stretching, immobilization, orthotics and injections. The patients provider has suggested the patient receive ESWT. The Health Plan has denied coverage for the proposed therapy citing a lack of proven efficacy.Although there is some evidence that ESWT can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed conservative therapy, 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. A recent randomized, placebo-controlled, double blind, clinical trial yielded results that contradicted the positive findings of previous studies, thus raising doubts regarding the efficacy of ESWT for patients with plantar fasciitis. At this time, there is nothing to indicate that ESWT is likely to be more beneficial for treatment of the patients condition than any conservative therapy. Therefore, the Health Plans denial should be upheld.Physician 3: The patient is a 56-year-old woman who has been diagnosed with plantar fasciitis. Based on the submitted progress notes and letters, the patient has been extensively treated for right heel/foot pain. Neurologic and MRI work-ups were performed. Unfortunately, it appears the patient has not responded to conservative care, including orthotics, cortisone injections, strapping, physical therapy, and NSAIDs. It has been recommended that she undergo ESWT to both heels to alleviate her plantar fasciitis pain. The Health Plan has denied authorization and coverage for ESWT on the basis that the requested therapy is considered investigational.In some circles ESWT for plantar fasciitis is still considered experimental and investigational. In other circles it is a well-accepted treatment option, demonstrating a 75-85% cure rate. There are numerous articles/studies published in peer-reviewed journals demonstrating the efficacy of ESWT for proximal plantar fasciitis. At issue in this case is whether ESWT is likely to be more beneficial for treatment of the patient's plantar fasciitis than endoscopic or open plantar fasciotomy. In light of the patient's past difficulties with open surgical procedures and her reactive arthritis condition, a less aggressive non-surgical approach to treatment would in general be more beneficial. It appears that the patient's orthopedist, neurologist, and rheumatologist are in agreement. Therefore, I have determined the requested therapy 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.