Diagnosis: Foot Pain (plantar faciitis).
Treatment: Durable Medial Equipment (custom shoe inserts).

The insurer denied the Durable Medial Equipment (custom shoe inserts).
The denial is upheld.

The patient is a male. The patient presented with the chief complaint of painful feet, specifically with pain in the anterior plantar foot (ball of the foot) with the presence of plantar callosities in the metatarsal head region. He has been treated with OTC (over the counter)/Custom (L3020) devices and debridement of the calluses.

No, the custom shoe inserts are not medically necessary.

The diagnosis of plantar fasciitis that is noted on the orthotic prescription and appeal letter is nowhere to be found in the medical notes. On the contrary, the notes document pain in the metatarsal head region rather than the arch/heel area, where plantar fasciitis pain would manifest itself.

Also the appeal letter states that the patient has already been using custom devices (L3020) without success. There is no reason to suggest that new custom devices would work better than the current ones.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.