DFU Denial Anthem

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Located in Indiana. Over the past year we have received a couple denials for HBOT with Anthem Medicaid.

In the denial letter Anthem references the MCG 27th Edition Ambulatory Care Guideline for HBO A-0250. I have searched everywhere for a copy of this guideline with no success. Our billing department has even requested a copy from Anthem with no avail.

In a specific denial, where we were requesting more therapy for a DFU, Anthem responded with "we cannot approve your request for 15 more (hyperbaric oxygen) treatment. This is because it is not medically necessary. We can approve 5 more treatments. You have a foot ulcer. The (maximum) number of treatments (40 total) will be reached with these treatments. We used MCG 27th Edition Ambulatory Care Guideline for Hyperbaric Oxygen, A-0250 to decide this"

Any help on locating a copy of the guideline would be appreciated.

Kind Regards,

Sean

Mar 20, 2024 by Sean Finley, EMT-B, CHT

2 replies

Elaine Horibe Song
MD, PhD, MBA

Hi Sean

Thanks for sharing this case. Other advisors might provide their input as well - we discussed with some advisors and were able to locate the specific paragraph of the guideline you mentioned that was likely used to make this decision. It reads as follows:

"A retrospective study of 1006 diabetic patients selected for hyperbaric oxygen therapy based on transcutaneous oxygen levels demonstrated that 73.8% of wounds granulated or healed after a mean of 34 treatments, and hyperbaric oxygen therapy was discontinued after a mean of 24 treatments in patients who failed to show any improvement. The authors acknowledged that there is diminished benefit after a total of 35 to 40 treatments (44)", where Reference 44 is Fife CE, Buyukcakir C, Otto G, Sheffield P, Love T, Warriner R 3rd. Factors influencing the outcome of lower-extremity diabetic ulcers treated with hyperbaric oxygen therapy. Wound Repair Regen. 2007 May-Jun;15(3):322-31.

According to the UHMS Hyperbaric Oxygen Indications 15th edition, Hyperbaric Oxygen Therapy for Selected Problem Wounds - Diabetic Foot Ulcer, "utilization review should be performed after the initial 30 days of treatment and at least that frequently thereafter." Therefore, in cases like the one described above in which the payer is approving 5 more treatments, even though the treatment threshold is 40 it is not uncommon that insurance carriers would expect medical necessity to be attested in order to continue to the maximum threshold. For instance in this case, once the approved number of sessions are completed, patient can be reevaluated and a new request can be submitted, provided there is objective utilization review and documentation supports medical necessity. The section 'Utilization Review' in topic "Diabetic Foot Ulcer - Hyperbaric Oxygen Therapy" provides guidance on important elements of a utilization review for DFU patients undergoing HBOT.

Hope this helps!

Mar 21, 2024

Elaine Horibe Song
MD, PhD, MBA

Mar 21, 2024

* Information provided without clinical evaluation and is not intended as a replacement for in-person consultation with a medical professional. The information provided through Curbside Consult is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

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