If you have questions about the practices of your managed-care coverage, ask the experts at the state Department of Managed Health Care.
Five years ago, I fractured my heel. Since then, I have had three surgeries, and I have no padding on my heel. Because I have no padding, I am walking on the bone. I have tried cortisone shots, special inserts, expensive shoes – you name it. Nothing works. Because of the pain, I have been compensating when I walk, and that is affecting my hips, knees and back. That is why I asked my health plan to cover silicone injections into my heel. I know it might not work.
Please help me convince my plan to cover these injections.
– Evelyn Doty North Highlands
The primary roles of the Department of Managed Health Care include ensuring that health plan members receive the care to which they are entitled, and that they receive medically necessary care in a timely manner.
When a health plan denies or delays a requested medical treatment, either because it is not deemed medically necessary or because it is considered experimental or investigational, the member can utilize the independent medical review, or IMR, process to have the health plan's decision reviewed by an independent doctor.
Because your health plan denied your request for silicone injections on the basis that the treatment was not medically indicated or appropriate for your condition, your request qualified for an IMR (at no cost to you).
The purpose of the IMR is to determine whether your health plan correctly denied your request for silicone injections as not medically necessary. For your case, the DMHC asked a practicing board-certified podiatrist to review your file and determine whether the silicone injections are a medically appropriate treatment for your condition.
The physician reviewer found that silicone injections for heel fractures are still under investigation, and there is no peer-reviewed evidence that shows they are effective for the treatment of heel pain occurring as a result of a fracture. There is also a lack of data to show such injections are safe. In the past, silicone injections have been linked to liver problems.
These findings led the reviewer to uphold your health plan's denial of silicone injections.
If you have been denied a treatment by a health plan and you want to find out if you can qualify for an IMR, call the DMHC's Help Center at (888) 466-2219 to talk to an agent, or log onto www.healthhelp.gov for more information.
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