202103-135938
2021
Fidelis Care New York
Medicaid
Orthopedic/ Musculoskeletal
Orthotics
Medical necessity
Upheld
Case Summary
Diagnosis: Orthopedic/Musculoskeletal-bilateral heel pain.
Treatment: Orthotics.
The insurer denied custom shoe inserts.
The denial is upheld.
The patient is a female who presented to her podiatrist for treatment of her bilateral heel pain, right greater than (>) left for the past 7 months or so. The patient reported continued pain in her right heel. She had previous cortisone injections but had a reaction to them. She has tried non-steroidal anti-inflammatory drugs (NSAIDs) but did not tolerate them due to gastrointestinal (GI) symptoms. She had her foot strapped which did not help. The patient has also been using prefabricated inserts, but they are not helping. She has also been stretching. Her provider is recommending custom molded orthotics. The issue is the medical necessity of the custom molded orthotics.
No, Based on all of the records that were submitted it appears that the patient has tried some tier 1 conservative measures. The patient had not tried a course of reasonable conservative measures before custom molded orthotics are recommended. Custom Molded orthotics are not considered a first line treatment options. Based on the submitted information, the custom molded orthotics were recommended as a first line treatment at the podiatrist initial treatment visit with the patient.
The patient has tried over-the-counter (OTC) prefabricated inserts, stretching, and previous cortisone injections which she had a bad reaction. However, it does not appear that the patient has tried the first line treatments according to the standard of care, such as physical therapy, home cryotherapy, shoe modification, or activity modification. The use of custom molded orthotics in this patient is not considered medically necessary at this time. The patient has not exhausted all conservative measures before custom molded orthotics should be tried.