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I just have a general question regarding CMS guidelines for using the Marx protocol 20:10 for dental tooth extraction for a high risk patient, under the diagnosis of STRN. Has there been any issues regarding audits with this? Is this considered generally acceptable by most?
Bill Khoury
Apr 21, 2022 by Bill Khoury,
5 replies
Jeff Mize
Dr. Kouhry, Thank you for your question. PROPHYLAXIS FOR TOOTH EXTRACTION
Extraction of teeth from heavily irradiated jaws is a common precipitating factor for mandibular necrosis. In roughly one half of cases of ORN of the mandible, extractions or some other surgery is the precipitating event. Marx advocated that in the treatment as well as prevention of ORN include an emphasis on pre-surgical, pre-extraction hyperbaric oxygen to improve tolerance to surgical wounding including the soft tissues surrounding the mandible. A report of 40 patients by Chavez and Atkinson in whom hyperbaric oxygen was applied in the manner described by Marx (20 pre-extraction hyperbaric treatments followed by 10 post extraction.) The authors reported that uncomplicated healing of tooth sockets was observed in 98.5% of extractions. Most patients received radiation doses between 6000 and 7000 cGy. When high risk patients are treated with HBO, the studies do support HBO in support of dental extractions. In order to sort out which patients are high versus low-risk categories, the hyperbaric physician must obtain the radiation records and ideally discuss the case with the treating radiation oncologist and oral surgeon given the complexity of the modern Intensity-modulated radiation therapy (IMRT)-based radiation treatment planning. (3)

Medicare covers perioperative use of HBOT as an adjunctive therapy for existing ORN Marx Stage I-III. Data to justify HBOT prophylaxis for osteoradionecrosis in a previously irradiated mandible undergoing tooth extraction is lacking at this time; subsequently this is a NON-COVERED SERVICE. (2)

Some commercial insurers including several BCBS plans will cover HBOT for the PREVENTION of ORN. The following language is present in the BCBS coverage determinations.

Coverage policy Position Statements: HBOT is indicated for the following conditions

• Soft tissue radiation necrosis (e.g., radiation enteritis, cystitis, proctitis) and osteoradionecrosis.
• Pre and post treatment for individuals undergoing dental surgery (non-implant related) of an irradiated jaw

• Soft-tissue radiation necrosis (e.g., radiation enteritis, cystitis, proctitis) and osteoradionecrosis
• Pre- and post-treatment for patients undergoing dental surgery (non-implant-related) of an irradiated jaw

• Soft-tissue radiation necrosis (e.g., radiation enteritis, cystitis, proctitis) and osteoradionecrosis
• Pre- and post-treatment for members undergoing dental surgery (non-implant-related) of an irradiated jaw.

1. First Coast Service Options, Inc., CMS Local Coverage Determination (LCD): Hyperbaric Oxygen (HBO) Therapy (L36504) https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36504
2. Hamm T, Mize J, Orr S, Song E, (2021). "Osteoradionecrosis - Mandibular". In Worth E, (Eds.), WoundReference. Available from: https://woundreference.com/app/topic?id=osteoradionecrosis-mandibular. Retrieved on 8/28/21.
3. Moon, R 2019: Undersea and Hyperbaric Medical Society Hyperbaric Oxygen Therapy Indications 14th Edition pg:271-273

I hope this helps. Please let us know if you have any additional thoughts or questions.

Apr 21, 2022
Thank you for the information. Just to clarify, for Medicare patients, treatment for high-risk patients dental extraction for prevention of ORN is not covered regardless of the ICD-10 code used. Using a STRN diagnosis to the gum/integument, would also not be appropriate as a covered benefit for CMS. I ask because under the HBO CMS requirement section, it stated that some HBOT clinics view the need for teeth extraction (without visible mandible) as a form of STRN. Appreciate the help.
Apr 21, 2022
Eugene Worth

Jeff is spot on … and, as you suspected, this may/may not be covered. Yes, you could be at risk of an audit.

So, here is what I have done. I carefully document the extent of the radiation injury in my exam. Such as … amount, dose, central maximum boost, etc. And, when it was administered. (Aside: If more than 6 months, you are on more firm ground to call this STRN of the mandible and neck.) I carefully describe the extent of external radiation damage … shiny, permanently sunburned, telangiectasias, etc. Then do the same for the mouth, if you can see it … also document no salivary function, odor, etc.

Now, you might call the oral surgeon or the dentist and have a short chat. If he/she documented that there was open mandible or visible mandible … especially that it appeared non-viable, then you clearly have a Marx grade in order to document the need for the protocol. If not, then we are usually out of luck. So, the surgeon takes out the teeth without HBOT. Then, if there is difficulty healing or open mandible needing debridement, we start the 30/10 protocol for open mandible. If you do get audited, you have a trail to the oral surgeon. So, I would be sure that they noted that on their medical record.

Sorry this isn’t a cut/dried issue. It depends a lot on the fiscal intermediary. If you have NOVITAS … well, good luck. If you have others, you might ask to speak with the medical director.
Apr 21, 2022
Eugene Worth
Oh ... and be sure to document that the affected tissue is within the radiation port. You can usually see the radiation tattoo mark on the neck, if you look carefully enough. The oral surgeon should have documented that the teeth involved are inside the radiation port, but you can work that out with him/her or the radiation oncologist. These folks are generally quite helpful if asked.
Apr 21, 2022
Perfect, thanks so much for the good advice!
Apr 21, 2022
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