Skin Ulcer: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) level of care. Findings: As noted in the medical literature, SNF admission may be indicated for patients with more than one wound, including a stage 3 pressure ulcer, rehabilitation, gait training, and observation. One study noted that, “Pressure ulcers (PUs) are injuries to the skin and underlying tissues that occur most commonly over bony prominences, such as the hips and heels as a result of pressure and shear forces.” Another study analyzed 477 patient records to determine the percentage of patients with pressure ulcers/injuries (PU/Is) who required admission to a SNF for wound care. The authors found that the majority of patients with a PU/I required admission from home to a SNF for appropriate care.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for additional hyperbaric oxygen therapy (HBOT) treatment. Although there are limited data from prospective randomized controlled clinical trials demonstrating improved health outcomes with HBOT in this patient’s clinical setting, there are data suggesting that HBOT may be beneficial. One study evaluated patients with nonhealing chronic wounds who were treated with HBOT. The authors found that “A majority of the patients in our study referred with nonhealing wounds clinically improved when adjuvant HBOT was added to standard wound care protocols.” Moreover, this patient’s records document clinical improvement with the first HBOT 20 treatment sessions.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for additional hyperbaric oxygen therapy (HBOT) treatments and wound healing treatments. Findings: The physician reviewer found that the records indicate that this patient’s ulcers have partially responded to standard compression therapy and there is a lack of documentation of wound hypoxia. In the current medical literature, there is insufficient evidence to support the use of HBOT for this patient’s venous ulcers. There are small case studies reporting that HBOT in combination with other modalities has resulted in improved healing of these types of ulcers. However, there is a paucity of evidence on the duration of healing or prospective trial data demonstrating superior clinical health outcomes with HBOT.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for continuation of long-term acute care hospital stay. Long-term acute care hospital level care is intended for patients who require care for more than one serious medical condition that is more medically complex than can be handled at lower levels of care such as inpatient rehabilitation facilities or skilled nursing facilities. The authors noted that an admission of 25 days or longer should generally be expected. The patient states that she has been hospitalized since February 2021. The patient was transferred back to a long-term acute care hospital, where he became significantly more medically stable and functional. By the date of denial, the patient was stable for discharge from the facility.

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 skin ulcer was denied, the published record says the denial is worth fighting.