Hyperbaric Oxygen Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 61-year-old male who in 1999 was diagnosed with prostate cancer with a Gleason score total of 7. He underwent radical retropubic prostatectomy with bilateral pelvic lymphadenectomy. Surgical margins were positive for cancer, and there was invasion of both seminal vesicles with a positive pelvic lymph node on the right side. He then underwent external beam radiation therapy for the prostate cancer. In July 2005, he was hospitalized because of abdominal pains and in July 2005 underwent laparotomy and sigmoid colon resection for poorly differentiated prostate adenocarcinoma invading the sigmoid colon. The patient also had mild left hydronephrosis and mild renal insufficiency, with BUN of 28 and creatinine of 2.0.

Physician 1: The patient is a 69 year old female that was diagnosed with breast cancer in March 1995. She was treated with lumpectomy and radiation. Subsequently, she was diagnosed with a rectal tumor in October 1995 and underwent surgery followed by chemotherapy and radiation therapy. The patient has developed radiation necrosis with soft tissue groin and perineal breakdown of a chronic nature such that blood transfusions and laser therapy have been necessary. Her provider has recommended hyperbaric oxygen (HBO) therapy for treatment of the patient’s non-healing wound.

Where the denial was upheld

Physician 1: This patient is a 54-year-old male diagnosed with Crohn’s disease that has recurrent pouchitis and severe perianal lesions. He has failed 6-mercaptopurine (6-MP), mesalamine (5-ASA) compounds and biologics including Remicade and Humira. The patient has been on high doses of oral steroids and has required frequent inpatient treatment. He has had an overall poor response to medical management. The patient’s provider requested authorization for hyperbaric oxygen therapy indicating it has provided some symptom relief for the patient in the past. The health plan has classified this treatment approach as investigational and denied the request for authorization and coverage. The patient has severe, refractory Crohn’s disease as evidenced by recurrent pouchitis and significant perianal involvement.

Physician 1: The patient is a 75-year-old male with a long history of a non-healing diabetic foot ulcer on the plantar left foot. His provider reports standard treatment modalities have been ineffective. The patient’s provider further states the patient has benefited from use of hyperbaric oxygen therapy. The Health Plan has denied coverage for hyperbaric oxygen therapy on the basis it is considered experimental for treatment of the patient’s condition. Review of the scientific evidence reveals there have been few trials involving hyperbaric oxygen therapy for diabetic ulcers. There is insufficient evidence hyperbaric oxygen therapy is superior to standard treatment modalities. In general there is limited quality data on the benefits of many of the therapies for diabetic ulcers. However, Regranex in sub-atmospheric oxygen dressing has been shown to be effective.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Hyperbaric Oxygen Therapy, then check the rights and deadlines that apply to your plan.