Description

Plantar fasciitis (heel pain syndrome), also known as plantar fasciosis, is an overuse injury resulting in inflammation of the connective tissue or plantar fascia on the sole of the foot and is one of the most common causes of heel pain in adults. The symptoms of plantar fasciitis may include localized pain at the heel or along the course of the plantar fascia that is more intense with the first steps in the morning or after a period of rest or inactivity. The plantar fascia is a thick fibrous connective tissue band that extends from the calcaneus (heel) to each toe on the bottom of the foot, supporting the arch and providing shock absorption for the foot and leg during walking.

Initial measures of conservative therapy may include avoiding barefoot walking and wearing flat shoes such as flip flops, decreasing physical activities that may be aggravating, icing, night splints, prefabricated or over-the-counter heel shoe inserts,

Plantar Fasciitis Treatments

Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0558-008

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

short-term trial of nonsteroidal antiinflammatory drugs (NSAIDs), specific plantar fascia stretching exercises or a walking boot/cast. An injection of a glucocorticoid with a local anesthetic in the tender areas of the plantar region may also be utilized. Additional therapies have been proposed if sufficient improvement is not achieved from initial conservative treatments.

Amniotic tissue derived allografts

involves the injection of amniotic tissue into the plantar fascia where there is maximum tenderness for chronic plantar fasciitis. Fetal tissues purportedly have unique healing properties not found in normal adult tissues that promote epithelialization and regeneration of damaged tissue and limit inflammation and formation of scar tissue. Amniotic tissues may be obtained when performing elective cesarean sections for healthy pregnancies, then cleansed, sterilized and processed. Processes for preserving human amniotic tissues include dehydration and cryopreservation. Several human amniotic tissue derived allografts are available. (Refer to Coverage Limitations section)

Autologous whole blood injection

involves the injection of an individual’s own whole blood into the plantar fascia on the basis that it contains various growth factors that purportedly begin a cascade of local factors to stimulate angiogenesis and healing. (Refer to Coverage Limitations section)

Coblation

is a patented process which causes molecules in body fluids to become highly energized and converted into a gas at low temperatures purportedly minimizing damage to surrounding tissues. This process is used in surgical instrumentation to destruct small segments of a tendon or connective tissue purportedly to stimulate blood vessel development and healing of damaged tissue. An example of a US Food & Drug Administration (FDA) approved coblation surgical instrument is the Topaz MicroDebrider. (Refer to Coverage Limitations section)

Cryosurgery

, also known as cryoablation or cryotherapy, involves external use of liquid nitrogen or argon gas at extreme cold temperatures to destroy diseased tissue. The liquid nitrogen is applied directly with a cotton swab or spray device. (Refer to Coverage Limitations section)

Extracorporeal shock wave therapy (ESWT)

is a nonsurgical treatment that involves the delivery of shock waves to the heel with the goal of reducing pain and promoting healing of the affected soft tissue. Shock waves are theorized to reduce inflammation, break up scar tissue and stimulate tissue healing.

ESWT Plantar Fasciitis Treatments Effective Date: 07/27/2023 Revision Date: 07/27/2023 Review Date: 07/27/2023 Policy Number: HUM-0558-008 Page: 3 of 12 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

is performed on an outpatient basis and may utilize local anesthesia to numb the area targeted for treatment. ESWT purportedly may be a noninvasive alternative to surgical treatment in selected individuals who have failed conventional medical therapy. (Refer to Coverage Limitations section)

Iontophoresis

uses electrical impulses to facilitate absorption of topical medication, dexamethasone, for the treatment of plantar fasciitis, into the tissue beneath the skin.16 (Refer to Coverage Limitations section)

Low level laser therapy (LLLT)

, also known as cold laser therapy, uses red beam or near infrared nonthermal lasers with a wavelength between 600 and 1000 nanometers and from five to 500 milliwatts. When applied, the lasers penetrate the surface of the skin without a heating (burning) effect, producing no sensation and do not damage the skin. It is believed that due to the low skin absorption and no side effects, the laser light can penetrate deeply into tissues and reach the site of damage or injury. It is theorized that LLLT may cause a biostimulatory healing effect. (Refer to Coverage Limitations section)

Minimally invasive cutting/shaving systems

deliver high pressured saline in a thin waterjet stream, using a 12-gauge needle or pump cartridge, capable of cutting and ablating damaged tendinopathic tissue. Suction is used to pull the damaged area into a window for cutting and removing the tissue. These devices are seen as alternatives to mechanical, radiofrequency and ultrasound cutting tools for tendinopathy treatment. An example of an FDA-approved cutting system is the TenJet device. (Refer to Coverage Limitations section)

Percutaneous ultrasonic ablation

combines the use of ultrasound imaging and minimally invasive pen-like surgical instrument that uses ultrasonic energy to visualize, cut and remove diseased and damaged tissue in patients with chronic tendinopathies. During the procedure the individual remains awake while the area of treatment is numbed with a local anesthetic. Ultrasound imaging is then used to locate the damaged tendon. A small incision is then made and the pen-like surgical instrument is placed in the incision to target, breakdown and remove the damaged tissue. An example of an FDA-approved ultrasonic ablation surgical instrument is the Tenex Health TX System.4 (Refer to Coverage Limitations section)

Platelet rich plasma injection (PRP)

is an adaptation of autologous whole blood injections. Whole blood is centrifuged to a concentrated state and is injected into the plantar fascia.16 (Refer to Coverage Limitations section)

Prolotherapy

is a pain management treatment that involves injecting a sclerosant (irritant) solution into the region of joints, muscles or ligaments and may be used to invoke the body’s natural inflammatory response purportedly promoting new tissue growth. Ruptured cells may release growth factors.

Prolotherapy

for plantar fasciitis involves administering a local anesthetic and then injecting a dextrose solution with a peppering technique, starting from the bony prominence under the weightbearing portion of calcaneus, along the medial plantar fascia.3 (Refer to Coverage Limitations section)

Radiofrequency ablation

is performed by inserting electrodes directly into the affected area where alternating high frequency current is then emitted. The current moves from the tip of the electrode into the surrounding tissue. The movement of ions results in frictional heating of the tissue and as the temperature becomes elevated beyond 60 degrees Celsius, cells around the electrode undergo necrosis (begin to die). (Refer to Coverage Limitations section)

Radiotherapy

uses ionized radiation to treat plantar fasciitis. This treatment is used in some parts of Europe.16 (Refer to Coverage Limitations section)

Trigger point needling or dry needling treatment

uses needles that are inserted directly into a myofascial trigger point, to inactivate it, thereby decreasing the associated pain. In trigger point or dry needling, there is no injection of medication or fluid. (Refer to Coverage Limitations section)

While many individuals with plantar fasciitis can be successfully treated with conservative measures, surgical intervention may be considered when plantar fasciitis has been refractory to conservative treatment for at least 6 months and is considered the last line of therapy. It is important to note the possibility that no improvement may occur after surgery.2 Recommended surgical procedures are described as follows:

• Decompression or neurolysis of a single nerve releases entrapment or chronic compression of the first branch of the lateral plantar nerve (Baxter’s nerve). The procedure involves utilizing an incision (cut) to release the deep or superficial fascia of the abductor hallucis muscle relieving compression on the nerve. This procedure accompanies the plantar fascia release.
• Exosteotomy of the calcaneus (heel) or calcaneus ostectomy for a bone spur procedure removes the spur when located on the heel. This procedure may accompany a plantar fascia release.
• Gastrocnemius lengthening, also known as recession, release or Strayer procedure, lengthens the gastrocnemius (calf muscle) by cutting the tendon when calf tightness prevents the ability to flex the foot including after a failed stretching regimen. The cut tendon then heals in a lengthened position.

Plantar Fasciitis Treatments Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0558-008
Page: 5 of 12
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Calf tightness may contribute to many foot problems including heel pain. Plantar fasciectomy/fasciotomy (endoscopic and open) or plantar fascia release involves partially cutting or completely removing a segment of the plantar fascia ligament to relieve tension in the tendon. For information regarding arch supports, foot orthotics or splints, please refer to Orthotics Medical Coverage Policy.

Coverage Determination

Humana members may be eligible under the Plan for surgical intervention for chronic plantar fasciitis utilizing the following procedures:

• Exosteotomy/ostectomy of the calcaneus for bone spur; OR
• Gastrocnemius lengthening; OR
• Nerve decompression or neurolysis; OR
• Plantar fasciectomy/fasciotomy (endoscopic or open);

AND when the following criteria are met:

• Failure of at least 6 months of conservative treatment under the direction of a healthcare professional including:
  • Activity/lifestyle modification; AND
  • Glucocorticoid injection when medically appropriate and not contraindicated; AND
  • Nonsteroidal anti-inflammatory drugs (NSAIDS) when medically appropriate and not contraindicated; AND
  • Physical therapy (PT) including home exercise program (HEP) (for information regarding coverage determination/limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); AND
  • Prefabricated heel inserts (generally excluded by certificate); AND
  • Walking boot/cast if medically appropriate

Plantar Fasciitis Treatments Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0558-008
Page: 6 of 12
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Limitations

Humana members may NOT be eligible under the Plan for treatment of plantar fasciitis by the following methods:

• Amniotic tissue derived allografts or human amnion/chorion membrane injections (e.g., Amniofix, Epifix); OR
• Autologous whole blood injection; OR
• Coblation (e.g., Topaz); OR
• Cryosurgery; OR
• Extracorporeal shockwave therapy (e.g., focused, high energy, low energy, radial) (may be excluded by certificate); OR
• Iontophoresis; OR
• Low level laser therapy; OR
• Minimally invasive cutting/shaving systems (e.g., TenJet); OR
• Percutaneous ultrasonic ablation (e.g., Tenex); OR
• Platelet rich plasma injection; OR
• Prolotherapy; OR
• Radiofrequency ablation; OR
• Radiotherapy; OR
• Trigger point/dry needling

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about plantar fasciitis may be found from the following websites:

• American Academy of Orthopaedic Surgeons
• National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.