Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 46-year-old male with foot pain. He is requesting extracorporeal shockwave therapy to help alleviate his discomfort. The Health Plan has denied his 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 2: The patient is a 46-year-old male with chronic plantar fasciitis. He has been treated over the past few years with multiple oral medications, local steroid injections, physical therapy, orthotics, and acupuncture. Surgery was suggested since the patient is still experiencing pain. The patient wishes to undergo extracorporeal shockwave therapy (ESWT). The Health Plan has denied coverage for the requested therapy on the basis it is considered investigational for treatment of the patients medical condition.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 46-year-old male who has experienced bilateral heel pain since November 2003. He has undergone multiple treatment options including physical therapy, cortisone injections, orthotics, and oral NSAIDS. The right heel pain has resolved, but his left heel remains tender. The patients provider recommended endoscopic plantar fasciotomy. The patient consulted another provider who recommended extracorporeal shockwave therapy (ESWT) to alleviate the patients left heel pain. The Health Plan has denied coverage for ESWT on the basis that the requested therapy 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. It has been recommended the patient undergo endoscopic plantar fasciotomy, which has carried an efficacy rate of over 90% for many years. The cure rate of ESWT ranges from 60 to 90%. Thus, there are other treatment options available to this patient that are more efficacious than ESWT. 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.