Diagnosis: plantar fasciitis.
Treatment: custom shoe inserts.
The health plan denied the requested custom shoe inserts as not medically necessary. The heath plan's determination is upheld.

The patient is a male that was initially seen for complaints of flatfeet. He stated that his old orthotics are worn out. He has pain with prolonged walking and standing to both of his feet. His previous treatment was custom orthotics. On exam, he was noted to have flexible flatfeet with excessive pronation. There was no pain noted to his feet. He was diagnosed with flatfeet. He was recommended custom foot orthotics at that visit. He was then seen by another provider complaining of painful feet all of the time. The patient was noted to be wearing prefabricated orthotics for the previous 3 months but still had pain. On exam, the patient was noted to have pain on palpation of heels, medial central band plantar fascia bilaterally, medial ankle ligaments bilaterally. He was diagnosed with plantar fasciitis. He was recommended stretching, wearing supportive shoes and recommended custom foot orthotics.
Then, the patient presented for an orthotic consult. He was complaining of pain to both heels and arches. He stated he had old pair of custom foot orthotics (CFO) that had gotten worn out. He attempted switching to over-the-counter (OTC) inserts but did not get relief. On exam, there was tenderness noted to medial calcaneal tubercle. The patient was diagnosed with plantar fasciitis. The patient was recommended custom molded orthotics.
The issue is the medical necessity of the custom shoe inserts.

I uphold, in whole, the health plan's determination of medical necessity.

No, the requested health service/treatment of custom shoe insets are not medically necessary for this patient.
The patient initially had foot pain and was diagnosed with plantar fasciitis. As part of the treatment plan, the patient was given custom molded orthotics. The patient appeared to have a flare up of his plantar fasciitis. This flare up should be treated similarly to the initial diagnosis with an appropriate amount of conservative care. There is insufficient documentation of an appropriate amount of conservative treatment before custom molded orthotics are recommended. Custom orthotics should not be first line treatment options. Thus, the requested custom shoe inserts are not medically necessary.