Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 47-year-old woman with bilateral plantar fasciitis. The patient was treated with medications, rest, injections and orthotics. In June 2004, she underwent extracorporeal shock wave therapy (ESWT). She is requesting reimbursement for this procedure. The Health Plan has denied this request indicating the procedure at issue is considered experimental.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 procedure or the associated complications or risks. Therefore, standard of care modalities would have been medically appropriate in this case.Based upon the information set forth above, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Accordingly, the Health Plans denial should be upheld.Physician 2: The patient is a 47-year-old female with plantar fasciitis. She has tried many conservative treatments without sustained relief. Her physician recommended she undergo extracorporeal shock wave therapy (ESWT), which was performed in June 2004. The Health Plan has denied reimbursement for ESWT citing a lack of proven efficacy.Review of the medical literature reveals several studies have demonstrated the efficacy of ESWT for the treatment of plantar fasciitis. The FDA has approved ESWT for the treatment of plantar fasciitis that has not responded to conservative treatment. Based upon the information provided, the patient met criteria for ESWT, as she failed medications, injections, and orthotics. Therefore, I have determined that the procedure at issue was 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 3: The patient is a 47-year-old woman who has requested reimbursement for extracorporal shock wave therapy (ESWT) for the treatment of chronic plantar fasciitis. The Health Plan has denied this request indicating that the procedure at issue is considered experimental for the treatment of the patients condition. Review of the documentation provided indicates the patient has failed multiple conservative treatment plans utilizing rest, steroid injections, NSAIDs, and orthotics. Since the patient was still experiencing plantar fasciitis pain, the provider suggested ESWT. The patient underwent ESWT in June 2004. Review of the relevant literature shows there is some evidence 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 a lack of 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 contradict the positive findings of previous studies, thus, raising doubts regarding the efficacy of ESWT for some patients with plantar fasciitis. At this time there is insufficient evidence indicating the procedure at issue was likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. Accordingly, the Health Plans denial should be upheld.