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Utilization Review

Utilization Review

Utilization Review

INTRODUCTION

Background

Definition

Utilization review is the systematic review of medical necessity, appropriateness, and reasonableness of services proposed or provided services to a patient or group of patients. This review may be conducted on a prospective, concurrent, and/or retrospective basis to reduce the incidence of the unnecessary and/or inappropriate provision of services.

  • A prospective review is conducted at the onset of a service or treatment. This review is performed before care is rendered in order to eliminate or reduce unnecessary services. A prospective review may be performed by the Medical Director to expedite care in emergent cases
  • A concurrent review is performed during the course of treatment.
  • A third party peer review may be indicated when exceeding the maximum number of HBOT for a given diagnosis. This third party can be from another HBOT center in your large hospital organization, or it may be from another institution. 
  • A retrospective review is conducted after the service has been completed and assesses the appropriateness of the procedure, setting, and timing in accordance with specified criteria.
When should utilization review be performed?

Utilization Review will be performed for all patients that receive hyperbaric oxygen therapy (HBOT) to determine medical necessity and appropriateness for patient treatment and utilization of services.

Of note, HBOT involves an initial evaluation that identifies and accurately describes the diagnosis of the medical condition supporting that the use of HBOT is reasonable and medically necessary. The evaluation will also identify underlying medical conditions that may make patients more likely to experience side effects from HBOT. Evaluating patients for specific underlying medical problems can reduce the potential for side effects and complications from HBOT. The risk(s) of HBOT side effects must always be evaluated in the context of the potential benefit of HBOT for a given condition. The HBO consultation should be easily identifiable and separate from the wound consultation. 

who should perform utilization review?

The utilization review will be performed by a committee of peers institutionally credentialed to perform hyperbaric oxygen therapy. The utilization committee will include at a minimum the hyperbaric Medical Director, nurse manager, and safety director. In select cases (e.g. course treatment outside the accepted UHMS treatment threshold), a third party peer review may be indicated based on institutional policy and is usually based on the patient’s medical record documentation. Ideally, a third party peer review is performed by a hyperbaric physician who has not given care to that patient. Generally, this physician is someone within your hospital network and someone who can view the electronic medical record of the patient but practices in another hyperbaric unit. The purpose of the third party peer review is to provide the insurer or fiscal intermediary an impartial review that supports your decision to continue HBOT after reaching what is considered the maximum number of treatments. If this third-party reviewer cannot easily/readily be found, then the HBOT physician is obligated to state the clinical needs for HBOT continuation in a separate medical decision making note, and an internal (e.g., the clinic medical director) peer reviewer performs the 'third party review.'  

POLICY

  1. Utilization and peer review will be performed for all patients receiving hyperbaric oxygen therapy. Undersea & Hyperbaric Medical Society (UHMS) treatment guidelines and CMS National Coverage Determination (NCD) 20.29 will be used to determine clinical appropriateness based on the diagnosis and treatment protocol.
  2. The hyperbaric physician will, upon initial consultation, determine the diagnosis and the appropriate treatment protocol. HBOT protocol will be based on Undersea & Hyperbaric Medical Society (UHMS) guidelines.
  3. The hyperbaric physician(s) ordering HBOT will be notified of any patient not meeting the criteria established by the UHMS or CMS NCD 20.29, and to the Medical Director if the ordering physician does not concur with the criteria or clinical interpretation of the case.
  4. If the documentation does not support the treatment or diagnosis, the Medical Director will contact the ordering hyperbaric physician to determine a plan of care.
  5. Patients not meeting the criteria established by the UHMS or CMS NCD 20.29 will be discussed with the attending hyperbaric physician and may be referred to the Medical Director of the Hyperbaric Medicine Service if the ordering physician does not concur with the criteria clinical interpretation of the case.
  6. Utilization review activities are confidential.
    1. The Medical Director will discuss the need for treatment on each patient requiring HBOT. When clinically appropriate the medical director and attending hyperbaric physician will determine if hyperbaric treatment should begin.

UTILIZATION REVIEW

The table below illustrates triggers for utilization review, based on indications for HBOT

Indications
Prospective
Concurrent
Third party peer review
Retrospective
Central Retinal Artery Occlusion (When treatment starts within 24 hours of vision loss)
Prior to the initiation of treatment 
> 5 sessions (3 days)

> 4 days after symptoms stabilize with no further improvement in visual acuity

At the completion of hyperbaric services
Diabetic Foot Ulcers (Wagner Grade 3 or higher)
Prior to the initiation of treatment
At least every 30 days during treatment
Third party peer review (> 40 treatments)
At the completion of hyperbaric services
Acute Carbon Monoxide Poisoning (And/Or Acute Cyanide Toxicity)
Prior to the initiation of treatment
After 3 treatments in 24 hours and After 6 total treatments
Third party peer review (After 10 total treatments)
At the completion of hyperbaric services
Clostridial Myonecrosis (Gas Gangrene)
Prior to the initiation of treatment
Concurrent review (After 10 total treatments)
After 15 treatments
At the completion of hyperbaric services
Compromised flaps and grafts
Prior to the initiation of treatment
 After 10 treatments and After 20 treatments
After 25 treatments
At the completion of hyperbaric services
Crush Injuries and Compartment Syndromes
Prior to the initiation of treatment
 After 10 treatments and After 20 treatments
After 25 treatments
At the completion of hyperbaric services
Decompression Illness (Including Arterial Gas Embolism
Prior to the initiation of treatment

 After 10 treatments (preferably in conjunction with recommendations from Divers Alert Network physicians

At the completion of hyperbaric services
 Delayed Soft Tissue Radiation Injuries
Prior to the initiation of treatment
 After 20 treatments and after 40 treatments
After 60 treatments
At the completion of hyperbaric services
Idiopathic Sudden Sensorineural Hearing Loss (Patients presenting within14 days after onset)
Prior to the initiation of treatment
After 10 treatments: Must include audiogram evidence of improvement

Third party peer review ** There is no data to show continued improvement beyond 20 treatments**

At the completion of hyperbaric services
 Mucormycosis and Cranial Abscesses
Prior to the initiation of treatment
After 20 treatments
After a course of therapy exceeding 20 treatments
At the completion of hyperbaric services
Necrotizing Soft Tissue Infections (Including Fornier’s Gangrene)
Prior to the initiation of treatment
After 10 treatments and After 20 treatments
After 30 treatments
At the completion of hyperbaric services
Chronic Refractory Osteomyelitis
Prior to the initiation of treatment
After 20 treatments and after 30 treatments
After 40 treatments
At the completion of hyperbaric services
Profound Anemia
Prior to the initiation of treatment
After 10 treatments and after 20 treatments
After 30 treatments
At the completion of hyperbaric services
Thermal Burns
Prior to the initiation of treatment
After 30 treatments
After 30 treatments
At the completion of hyperbaric services




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NOTE: This is a controlled document. This document 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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