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MRI reveals Osteonecrosis of hip post radiation for CA several years ago. Patient with debilitating pain.
Is there a way to provide HBO for this patient as osteoradionecrosis although not mandible or is there a soft tissue component to the pain the patient is experiencing? Payor is Medicare.
Nov 15, 2019 by kim posten,
5 replies
Eugene Worth
MD, M.Ed., FABA, ABPM/UHM
Kim:

That's a great question for which there is no straightforward answer. I'm going to ask for some more details on your part and give you some ideas on my part. First, are you sure that the area of bone in question is within the radiation field? You will have to ask that question to your radiation oncology department. It would also help me to know what kind of cancer this is ... I'm going to guess a sarcoma just based on the location you have described.

Are you absolutely sure that the bone disorder is related to the radiation? (From a Medicare perspective, that link is imperative.) If so, you could make a case for osteonecrosis of the femoral head. If I had this patient (and more clinical details would help), I would make the history as involved as I could to support that diagnosis. Your physician must document a history of cancer, the area of the body treated by radiation, the location of the radiation field, the total dose of radiation in the area that the MRI shows injury, the proximity of the bone in question to the radiation field, the type of injury now occurring, and the potential surgical intervention, if needed.

So, it would help to know that the bone has a visible pathologic fracture or what distinct radiographic changes that the radiologist interprets as osteoradionecrosis. (I'm pressing on this diagnosis to be certain that the radiologist didn't say aseptic osteonecrosis of the femoral head ... That would be a totally different subject.)

In summary, this is complicated. I don't think I've ever seen osteoradionecrosis of the hip. Primarily, we look at ORN of the mandible as significant b/c there is only one artery supplying blood to the mandible. That is not the case in the hip. More pertinent information, if you can share it, might change my mind, but I would approach this very carefully. You would be in the Medicare cross-hairs for continual audits, and as far as I know, has not been described in the literature where HBOT has been used. It would be much easier is there was a demonstrable soft tissue injury as well. That makes a good history of STRN.

PS: I did a PubMed search ... the only paper was a pediatric paper dealing with marrow edema and aseptic osteonecrosis of the femoral head.
Nov 15, 2019
Thank you Dr. Worth,
Yes, I was surprised at the request, then looked at the diagnosis codes sent with the referral- soft tissue radionecrosis and osteonecrosis. And the fact the previous HBO physician declined to treat. But when I read the history, I thought It was at least a learning opportunity and maybe a reason to request prior auth from insurance. I appreciate any thoughts you have and the ones you have already shared.
Nov 18, 2019
Oh, and I have asked for the copy of the actual radiology report re findings.
Nov 18, 2019
Eugene Worth
MD, M.Ed., FABA, ABPM/UHM
Fine, Kim ... At this point, let’s wait to give more suggestions until we answer the questions remaining with data. While I do pay attention to referral codes, I kind of chuckle when non-hyperbaric physicians use hyperbaric codes. They are usually barking up the wrong tree.

That said, I feel for the patient and the terrible pain that he experiences. I wish there were a way to snap our fingers and make it go away. To progress with HBOT, let’s get the facts correct at the start.

I like your idea about a pre-authorization. I wish you would review the previous HBO physician’s note and see if you can determine why that physician declined to treat.

Thank you.
Nov 19, 2019
Most recent MRI "may represent an area of developing infarct/osteonecrosis"

Have called previouos HBO Center for notes re: not treating diagnosis after treating previous.

I will let you know when they arrive.

Thanks!
Nov 19, 2019
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