Diagnosis: Achilles bursitis/tendonitis.
Treatment: Durable medical equipment (Cam walker boot).

The insurer denied coverage for durable medical equipment (Cam walker boot). The denial is overturned.

The patient has chronic medical problems including cardiovascular disease, chronic obstructive pulmonary disease (COPD) and osteoarthritis. She was seen by a podiatrist complaining of a 7-week history of sharp, aching pain and swelling to the right Achilles tendon. The diagnosis was Achilles bursitis/tendonitis. The treatment plan included compression bandages, stretching, ice, supportive shoes, and steroid medication. She was seen for follow-up evaluation, with a reported 40% (percent) pain improvement and requested additional treatment options for pain relief. The doctor provided a Cam walking boot to her right lower extremity which is currently under review.

The provision of the Cam walker boot was clinically appropriate and medically necessary. A Cam walker boot is indicated for various conditions including severe ankle sprain, severe ankle or foot fracture, or recent surgery for the foot or ankle; additional indications include soft tissue injuries e.g. Achilles tear/rupture, Achilles bursitis/tendonitis and plantar fasciitis. The patient's soft tissue injury is appropriate for off-loading with a Cam boot which can benefit healing, recovery and pain relief; while limiting pain exacerbations and maintaining her ability to ambulate.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the durable medical equipment (Cam walker boot) is substantiated. The insurer's denial is overturned.