Denial Recommended
This request should be denied as the documentation does not demonstrate that the member has failed to respond to a course of appropriate conservative treatment, which is explicitly required by the policy criteria.
Policy Requirements Not Met
The policy CM.MED.147 clearly states that custom foot orthoses are considered medically necessary only when "the member has failed to respond to a course of appropriate conservative treatment (e.g., physical therapy, injections, strapping, anti-inflammatory medications)" and that "orthotics should not be considered first line therapy." 1
Documentation Deficiencies
The clinical documentation shows:
- No prior conservative treatment attempted: The patient is "not taking any pain relievers or using ice/heat" 1
- Current plan recommends conservative measures first: The physician's own treatment plan states "Recommend nsaids, ice" and only to "consider cfo's" 1
- No evidence of failed conservative therapy: There are "no prior rfls for cfo's" and no documentation of previous conservative treatment attempts 1
Conservative Treatment Requirements
Multiple guidelines emphasize that orthoses should not be first-line therapy. The American College of Foot and Ankle Surgeons recommends initial treatment with NSAIDs, padding and strapping, activity modification, and proper footwear before considering custom orthoses. 1 Only after 6 weeks of conservative treatment without improvement should advanced interventions like custom orthotic devices be considered. 1
For the specific conditions documented (hammertoe deformity, functional hallux limitus, bursitis, plantar plate tear), conservative management should include:
- NSAIDs for inflammatory conditions (bursitis, plantar plate pathology) 1
- Proper footwear modifications (shoes with firmer soles, avoiding barefoot walking) 1
- Activity modification and ice therapy 1
- Padding and strapping techniques 1
- Physical therapy or stretching exercises 1
Clinical Reasoning
While the patient has legitimate foot pathology that may eventually warrant custom foot orthoses, the policy explicitly requires documentation of failed conservative treatment. 1 The physician's own assessment recommends trying NSAIDs and ice first, acknowledging that conservative measures have not yet been attempted. 1
The appropriate pathway is: Deny the current request and recommend the patient complete a minimum 6-week trial of conservative treatment (NSAIDs, ice, proper footwear, activity modification) as outlined in the physician's plan. 1 If symptoms persist after documented conservative treatment failure, resubmission with documentation of these failed interventions would meet policy criteria. 1
Common Pitfall to Avoid
Do not approve custom orthoses simply because the diagnosis qualifies under the policy's condition list (hammertoe deformity, bursitis). The policy requires both an eligible diagnosis and documented failure of conservative treatment. 1 This is a two-part requirement that must both be satisfied.