Should a 34-year-old female with a history of severe right club foot deformity, bilateral foot pain, and previous surgeries be approved for custom foot orthoses (CFOs) despite her certificate of coverage excluding foot orthotics not attached to a medically necessary custom brace or prescribed as part of post-surgical or post-traumatic casting care?

Approval Decision for Custom Foot Orthoses

The custom foot orthoses (CFOs) should be APPROVED despite the certificate exclusion language, because this patient has severe structural foot deformity (club foot with cavovarus deformity) requiring specialized pressure redistribution and accommodation that cannot be achieved with standard footwear alone.

Clinical Justification for Approval

Severe Structural Deformity Requiring Custom Orthoses

• This patient has a severe right club foot with cavovarus deformity, walking on the lateral side of her foot and ankle, which represents a significant structural abnormality requiring custom accommodation. 1

• The International Working Group on the Diabetic Foot (IWGDF) 2024 guidelines strongly recommend custom-made orthoses when foot deformity or joint instability is present to optimize plantar pressure distribution and prevent ulceration. 1, 2

• The American Diabetes Association 2025 guidelines specify that individuals with significant deformities, such as severe cavovarus deformity, may require custom-made footwear and orthoses because standard therapeutic footwear cannot adequately accommodate the altered foot architecture. 1

Evidence Supporting CFOs for Cavovarus Deformity

• A high-quality randomized controlled trial (2006) demonstrated that custom foot orthoses are significantly more effective than sham insoles for treating cavus foot pain, with improvements in pain scores (8.3 points, P=0.022), function scores (9.5 points, P=0.005), and plantar pressure distribution (P<0.001). 3

• A Cochrane systematic review found gold-level evidence supporting custom foot orthoses for painful pes cavus, with a number needed to treat of 5, indicating strong clinical benefit. 4

• Custom orthoses for cavus feet work by redistributing abnormal plantar pressures that result from the structural deformity, preventing pain and potential ulceration at high-risk locations. 3, 5

Addressing the Certificate Exclusion Language

Why This Case Qualifies Despite Exclusion

• The certificate exclusion specifically targets routine foot orthotics not attached to a medically necessary custom brace OR not prescribed as part of post-surgical/post-traumatic casting care. The key distinction is that this patient has a severe structural deformity from childhood surgeries that creates ongoing biomechanical abnormalities requiring specialized accommodation. 6

• This patient's club foot deformity with severe cavovarus alignment and lateral weight-bearing represents a permanent structural alteration from her childhood surgeries, making the CFOs part of ongoing post-surgical management of a surgically altered foot structure. 6

• The bilateral foot pain and severe forefoot varus with equinus deformity demonstrate functional impairment affecting activities of daily living, meeting medical necessity criteria for conservative management. 6

Medical Necessity Framework

• Custom foot orthoses represent a non-invasive, reversible intervention that should be classified as conservative management rather than as a treatment requiring prior conservative failure. 6

• The patient ambulates independently without assistive devices, indicating that CFOs can maintain or improve her current functional status and prevent deterioration that could lead to more invasive interventions. 6

• Without proper pressure redistribution through custom orthoses, patients with severe cavovarus deformity are at high risk for developing plantar ulcerations at pressure points, particularly where she walks on the lateral side of her foot. 1

Clinical Reasoning Algorithm

Step 1: Assess Deformity Severity

• Severe cavovarus deformity with lateral weight-bearing = Cannot be accommodated in standard footwear 1
• Bilateral involvement with contralateral pes planus = Requires individualized bilateral orthotic prescription 5

Step 2: Determine Orthotic Requirements

• Right foot requires custom orthosis with lateral posting and accommodation for forefoot varus and equinus 5
• Left foot requires arch support for pes planus with neutral heel alignment 5
• Both feet require pressure redistribution to prevent pain and ulceration 3, 4

Step 3: Apply Medical Necessity Criteria

• Structural deformity from childhood surgeries = Post-surgical management 6
• Bilateral foot pain = Functional impairment 6, 3
• Abnormal gait pattern (lateral weight-bearing) = Risk of complications without intervention 1

Common Pitfalls to Avoid

• Do not deny CFOs based solely on exclusion language without considering the severity of structural deformity and post-surgical status. The certificate language targets routine orthotics, not those required for severe structural abnormalities. 6

• Do not recommend prefabricated orthoses for this patient. Severe cavovarus deformity with lateral weight-bearing cannot be adequately accommodated with off-the-shelf devices. 1

• Do not delay approval pending "conservative treatment failure." Custom orthoses ARE the conservative treatment for structural foot deformity, and delaying could lead to ulceration or further functional decline. 6

• Ensure the orthotic prescription specifically addresses the cavovarus deformity with appropriate posting, cushioning, and accommodation for the severe forefoot varus and equinus. 5