Osteomyelitis: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for hyperbaric therapy services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s chronic non-healing radiation induced wound and osteomyelitis of scalp bone.Findings: There is sufficient support in the medical literature and in the submitted documentation for the requested services in this clinical setting. There is significant evidence to support the use of hyperbaric therapy for radiation induced osteonecrosis and chronic refractory osteomyelitis. In addition, the Centers for Medicare and Medicaid Services guidelines support its use in individuals who have been diagnosed with radiation induced skin injury. This patient was seen by various disciplines and had undergone graft treatments.

The patient is a 63-year-old male with lower back pain secondary to osteomyelitis who was admitted to a skilled nursing facility after a hospital admission. The patient had a physical therapy evaluation in April 2005. At that time the patient required minimum assistance for bed mobility, moderate assistance with transfers, and minimum assistance with ambulation. In addition, the patient required minimum assistance with toilet hygiene and maximum assistance with lower back dressing and bathing. After seven days of therapy, the patient required contact guard assistance with bed mobility, contact guard assistance with transfers, and contact guard assistance with ambulation. At this time the patient had not completed his rehabilitation course and was expected to continue to progress. He had not reached his functional potential and he was not independent or safe to be alone.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyperbaric chamber therapy four times weekly Monday through Thursday 30 sessions. The records provided for review document that this patient presented to his provider status post fall off a ladder with a comminuted fracture of the right tibia and fibula with skin injury. The patient underwent open reduction with internal fixation (ORIF) with subsequent removal of some of the hardware. The provider charted that the patient’s surgical incisions appear to be healing well, but there was an area of necrosis with exposed hardware on the right medial lower leg. The provider recommended treatment with antibiotics, which was started. Prior to completion of the course of antibiotics the provider recommended treatment with hyperbaric oxygen therapy. The patient has a history of diabetes.

Nature of Statutory Criteria/Case Summary: A 65-year-old male enrollee has requested reimbursement for skilled nursing home care services provided for five (5) days at the end of September 2018. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee’s osteomyelitis.At issue in this case is whether the skilled nursing home care services at issue, provided from for five (5) days at the end of September 2018, were medically necessary for treatment of the enrollee’s medical condition.Per Hakkarainen and colleagues the surgical population is aging, and greater numbers of surgical patients are being discharged to skilled nursing facilities. Post-acute care is a poorly understood but very important aspect of our healthcare system.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for osteomyelitis was denied, the published record says the denial is worth fighting.