Tuesday, February 07, 2006

Important Stuff from UHMS About Blue Cross-Blue Shield

Here is some interesting material sent out by the UHMS. BC-BS is apparently limiting the scope of insurance coverage for hyperbaric treatment - unilaterally and possibly arbitrarily.

As you might be aware, several of the regional BlueCross BlueShield affiliated insurance companies have responded to a change in the national coverage policy for use of hyperbaric oxygen treatment recommended by the BlueCross BlueShield Association. We do not know the full extent to which local BlueCross BlueShield companies have adopted these recommendations which are summarized below.

Those conditions moved to the investigational category include:

Radiation necrosis (osteoradionecrosis and soft tissue radiation necrosis)
Refractory mycoses (mucormycosis, actinomycisis, canidiobolus coronato)
Cerebral edema
Chronic refractory osteomyelitis and acute osteomyelitis refractory to standard medical management
Acute peripheral arterial insufficiency
Necrotizing soft tissue infections
Carbon monoxide poisoning (see statement below)


This is the current (03.2005) nationally recommended coverage guidelines for adjunctive hyperbaric oxygen treatment…



Systemic hyperbaric oxygen pressurization may be considered medically necessary in the treatment of the following conditions:

1. non-healing diabetic wounds of the lower extremities in patients who meet the following 3 criteria:

a. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;

b. Patient has a wound classified as Wagner grade 3 or higher*; and

c. Patient has no measurable signs of healing after 30 days of an adequate course of standard wound therapy.

2. acute traumatic ischemia;

3. decompression sickness;

4. gas embolism, acute;

5. cyanide poisoning, acute.

6. gas gangrene (i.e., clostridial myonecrosis);

7. profound anemia with exceptional blood loss: only when blood transfusion is impossible or must be delayed;

* The Wagner classification system of wounds is defined as follows: grade 0 = no open lesion; grade 1 = superficial ulcer without penetration to deeper layers; grade 2 = ulcer penetrates to tendon, bone, or joint; grade 3 = lesion has penetrated deeper than grade 2 and there is abscess, osteomyelitis, pyarthrosis, plantar space abscess, or infection of the tendon and tendon sheaths; grade 4 = wet or dry gangrene in the toes or forefoot; grade 5 = gangrene involves the whole foot or such a percentage that no local procedures are possible and amputation (at least at the below the knee level) is indicated.

Hyperbaric oxygen pressurization is considered investigational in the treatment of acute carbon monoxide poisoning. Note: While evidence for the treatment of acute carbon monoxide poisoning with hyperbaric oxygen pressurization has failed to demonstrate improved health outcomes, this technology is accepted in medical practice as a standard medical therapy for the treatment of carbon monoxide poisoning.

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Hyperbaric oxygen pressurization is considered investigational in the treatment of the following conditions:

compromised skin grafts or flaps;
chronic refractory osteomyelitis and acute osteomyelitis, refractory to standard medical management;
necrotizing soft-tissue infections;
acute thermal burns;
spinal cord injury;
traumatic brain injury;
severe or refractory Crohn’s disease;
brown recluse spider bites;
bone grafts;
carbon tetrachloride poisoning, acute;
cerebrovascular accident, acute (thrombotic or embolic);
fracture healing;
hydrogen sulfide poisoning;
intra-abdominal and intracranial abscesses;
lepromatous leprosy;
meningitis;
Pseudomembranous colitis (antimicrobial agent-induced colitis);
radiation myelitis, cystitis enteritis, or proctitis;
sickle cell crisis and/or hematuria;
demyelinating diseases, e.g., multiple sclerosis, amyotrophic lateral sclerosis;
retinal artery insufficiency, acute;
retinopathy, adjunct to scleral buckling procedures in patients with sickle cell peripheral retinopathy and retinal detachment;
pyoderma gangrenosum
acute arterial peripheral insufficiency
acute coronary syndromes and as an adjunct to percutaneous coronary interventions
acute ischemic stroke
idiopathic sudden sensorineural hearing loss
radiation necrosis (osteoradionecrosis and soft tissue radiation necrosis);
refractory mycoses: mucormycosis, actinomycosis, canidiobolus coronato;
cerebral edema, acute;
migraine;
in vitro fertilization; and
cerebral palsy.


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The UHMS is taking the following actions regarding this critical issue:

We need to understand the extent of the problem. Since commercial insurance companies are not required to make their internal medical policies public, the only way we will know the extent of the problem is to have our member physicians report to us any notices of policy changes under consideration or actual denials for hyperbaric oxygen treatment based on non-coverage. To do that, we are requesting that you fax any BlueCross BlueShield communication (claim denial letter, etc., after removing patient specific identifying information) to Tom Workman, Director, Quality Assurance & Regulatory Affairs, at 1-210-404-1535. We will tabulate this information to give us a better idea of the scope of this problem. Also, your communication with Tom will help us identify member physician contacts to assist the Society in meeting with individual BlueCross BlueShield medical directors. Please also provide for us the name of your BlueCross BlueShield associated insurance company medical director and his contact information.

The Society will provide you over the next few weeks (on request) a sample letter for each of the primary denied coverage indications summarizing the critical clinical information supporting the use of hyperbaric oxygen treatment and a brief bibliography of pertinent references with commentary if needed.

We will also be providing you with a process outline to follow in submitting your appeal and in working with the UHMS to assist you with additional information as needed.

On the national level, the UHMS is in the process of developing a detailed response to BlueCross BlueShield to be presented at the national and regional level.
The Society will keep you informed of our actions and the responses provided by various BlueCross BlueShield affiliated companies as well as the availability of the resources mentioned above. Watch the UHMS website (www.uhms.org) or your email for these updates.


* Note from scubadoc: If a treatment modality is limited to conditions where there is definite proof of efficacy in humans - how can studies ever be done that show double blinded benefit for "investigational conditions"?

Below are some related web pages on our Diving Medicine Online web site:

1. Hyperbaric Oxygen Treatment, Abstract and Full Text of JAMA Article
diving and undersea medicine for the non-medical diver, the non-diving ... Diving Medicine Online Hyperbaric Oxygen Therapy (JAMA Article) Hyperbaric Oxygen Therapy from "JAMA" "The
http://www.scuba-doc.com/hbotrtmnt.html

2. Links to HBO Therapy
diving and undersea medicine for the non-medical diver, the non ... in ambulatory care for those suffering from wounds. Our ... quality books on hyperbaric medicine, diving medicine and wound
http://www.scuba-doc.com/hbolnks.htm

3. HBO...Indications, contraindications, links references
and undersea medicine for the non-medical diver, the ... Diving Medicine Online Hyperbaric Oxygenation HBO Indications AMA Article on HBO ... Chambers HBO for Sudden Deafness? Disclaimer
http://www.scuba-doc.com/hbo.html

4. Contra-indications to HBO
the use of hyperbaric oxygenation. HOME HBO HERE Scubadoc's Diving ... and undersea medicine for the non-medical diver, the ... as chemotherapeutic agents for cancer. HBO and doxorubicin
http://www.scuba-doc.com/hbocont.htm