Is a request for custom foot orthotics (CFOs) approved for a patient with a tear of the second plantar plate and significant pain, despite lack of documentation of failed conservative treatments?

Authorization Decision for Custom Foot Orthotics

This request should be DENIED based on the policy requirement for documented failure of conservative treatment, which has not been met in this case.

Policy Analysis and Clinical Context

The GHC-SCW policy CM.MED.147 explicitly requires that conservative medical management has failed before approving custom foot orthotics for diagnoses not specifically listed in the policy [@policy requirement]. A plantar plate tear falls into this category requiring documentation of failed conservative treatments.

Current Clinical Situation

The patient presents with:

• Second plantar plate tear confirmed by ultrasound
• Pain rated 4/10 (moderate severity)
• Symptoms present for only 4 weeks
• Pain worse with prolonged standing and daily activities
• No documented trial of conservative treatments prior to this orthotic request

Why Conservative Treatment Documentation is Required

The 4-week symptom duration is insufficient to demonstrate treatment failure. The clinical note indicates that custom foot orthotics were "discussed" as conservative treatment to offload the plantar plate, but there is no documentation that other first-line conservative measures were attempted and failed [@policy requirement].

Standard Conservative Treatment Pathway

Before custom orthotics are indicated, patients with plantar plate pathology should document trials of:

• Properly fitting footwear modifications - The International Working Group on the Diabetic Foot recommends instructing patients to wear properly fitting footwear when foot deformity or pathology is present 1
• Prefabricated orthoses or shoe inserts - Research demonstrates that prefabricated orthoses provide similar pain relief to custom orthoses for foot pain conditions and should be tried first 2, 3
• Activity modification and offloading strategies - Temporary footwear modifications or shoe changes to reduce pressure on the affected area 1
• Anti-inflammatory measures and physical therapy - Standard conservative care for plantar forefoot pathology 4

Evidence Supporting Conservative Treatment First

A 2018 systematic review and meta-analysis found no significant difference between prefabricated orthoses and custom orthoses for pain relief in plantar foot conditions 3. A 2008 Cochrane review similarly concluded there is limited evidence supporting custom-made foot orthoses over other conservative treatments for various foot pain conditions 2.

Prefabricated orthoses cost significantly less than custom orthotics and provide comparable outcomes, making them the appropriate first-line intervention 5, 4.

Clinical Reasoning for Denial

1. Insufficient treatment duration: 4 weeks is too short to determine if conservative measures would be effective
2. No documented conservative treatment trials: The medical record shows discussion of orthotics but no evidence of attempting prefabricated insoles, shoe modifications, or other standard treatments
3. Moderate pain level: A pain score of 4/10 suggests the condition may respond to less invasive interventions
4. Policy compliance: The policy explicitly requires failure of conservative management before approval [@policy requirement]

Recommended Next Steps

The ordering physician should document:

• Trial of prefabricated orthoses or over-the-counter arch supports for at least 6-8 weeks [@15@]
• Footwear assessment and modifications to ensure proper fit and offloading [@2@]
• Activity modification and home exercise program targeting foot mechanics
• Follow-up assessment after conservative treatment trial to document response or lack thereof

If symptoms persist or worsen after documented trials of these conservative measures (typically 6-12 weeks), resubmission for custom foot orthotics would be appropriate and would meet policy criteria [@policy requirement, 4].

Important Caveat

If the patient's symptoms significantly worsen or if there is evidence of progressive structural damage on follow-up imaging, earlier consideration of custom orthotics or surgical consultation may