Shoe Inserts for Foot Disorder: 81.0% of denials overturned
In 21 California IMR decisions from 2010 to 2025, reviewers overturned 17 (81.0%). In the last five years: 100.0% of 5. 21 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 100.0% |
| 2023 | 1 | 100.0% |
| 2024 | 2 | 100.0% |
| 2025 | 1 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 8 | 75.0% | 81.0% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 5 | 100.0% | 81.0% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 3 | 0.0% | 81.0% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for custom foot orthotics (shoe inserts/insoles). In this case, the patient is noted to be suffering with painful metatarsalgia and Morton’s neuromas bilaterally with the patient’s pain occurring below the second and third toes. The patient has been treated with numerous injections in …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for custom molded foot orthotics. The literature shows that conditions such as sesamoiditis have been treated conservatively with the usage of custom foot orthotics. This patient has a history of right foot pain, a closed fracture of the sesamoid bone of the right …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for custom shoe inserts/orthotics. The medical documentation supports that this patient presents with left first and second metatarsophalangeal joint pain upon ambulation. X-rays revealed a shortening of the first metatarsal with arthritic changes to both the first and second metatarsophalangeal joints. appears to …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for shoe inserts (custom molded orthotics). The submitted documentation fails to demonstrate the medical necessity of the requested equipment. Walther and colleagues noted that supportive orthotics are superior to non-supportive orthotics regarding pain reduction in treatment of plantar fasciitis. This patient has been diagnosed with plantar fasciitis bilaterally, …”
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
How often were Shoe Inserts denials for Foot Disorder overturned?
In 21 California IMR decisions from 2010 to 2025, reviewers overturned 17 (81.0%). In the last five years: 100.0% of 5. 21 were medical-necessity disputes.
What should an appeal document, based on these findings?
Whatever the plan's criteria ask for, shown in the record: the treatments already tried and their results, contraindications to the plan's preferred option, the guideline or evidence that supports the request, and the treating clinician's reasoning written to the criteria. The tag table shows which of these the reviewers mentioned most in overturned cases.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but they weigh the same things.
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.