BIG FAT LOOPHOLE FOR MEDICARE /MEDICAID HYPERBARIC THERAPY

[ladycolorado]

check your local hospitals see if offer hyperbaric therapy and ask the approved uses for it under medicare medicaid. chronic wound therapy is one of them. and since wounds might have infection, amy get some meds too. MENTION NOTHING OF MORGELLONS DISEASE/CHRONIC LYME, OKAY. as long as get treatment need, who cares if they are ignorant (LC). if hopital center does have ad take medicare medicaid ask what is covered and if need a referral etc. check with them what poroper channels to go through to make sure covered.alot of the conditions we suffer from legitmate causes even in their eyes. might need a referral i will try to dig more into that, (LC).

[ladycolorado]

Title of Policy

Hyperbaric Oxygen Therapy for Medicare Plans
The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies as well as SecureHorizons®/Oxford and Evercare.

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.


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Policy #: REHAB 018.3 T2

Coverage Statement:

Policy is applicable to:

Medicare plans:
SecureHorizons/Oxford - MedicareComplete Plans and Evercare Plan DH, including Group Retiree Plans effective January 1, 2007
Oxford Medicare Advantage plans, including Medicare Group Accounts (MGA) effective until December 31, 2006
For Commercial plans, refer to Oxford policy: Hyperbaric Oxygen Therapy for Commercial Plans


Conditions of Coverage Benefit Type General benefits package
Referral Required
(Does not apply to non-gatekeeper products) No
Authorization (Precertification always required for inpatient admission) Yes
Precertification with MD Review No1
Site(s) of Service
(If not listed, MD Review required) Outpatient
Special Considerations 1Medical Director review required after 10th treatment session.
Medical Director review required for all requests for therapy for any condition not included on the list of covered diagnosis codes in this policy.


Description of Service/Assessment/Background Information:
Hyperbaric oxygen (HBO) therapy is the administration of oxygen at higher than normal pressure.

Systemic Hyperbaric oxygen is a medical treatment by which oxygen is administered at greater than normal pressure to treat specific medical conditions (e.g. carbon monoxide poisoning, decompression illness, and gas gangrene). During HBO therapy the patient is placed in a specially designed chamber and breathes 100 percent oxygen for a designated period of time (up to two hours). Alveolar oxygen pressure is increased, causing a rise in plasma oxygen content that result in enhanced tissue oxygen delivery.

HBO therapy is also used as an adjunctive therapy in the management of a variety of disorders notably diabetic wound healing problems, chronic bone infections, and radiation injury.

Topical HBO therapy is administered to the open wound in small limb-encasing devices. It does not meet the definition of systemic HBO therapy and its efficacy has not been established in the peer review medical literature due to the lack of controlled clinical trials. Examples of topical HBO therapy devices are TOPOX, Oxyboot, and Oxyhealer.

Topical HBO is not covered by Oxford Health Plans or by the Centers for Medicare & Medicaid Services (CMS).

Refer to Oxford policy: Topical Oxygen Therapy for Chronic Wounds.
Policy and Rationale:
Oxford and CMS will cover systemic HBO therapy as a primary or adjunctive mode of therapy for medically necessary conditions.

Oxford and CMS do not provide coverage for topical therapy or the rental or purchase of topical hyperbaric oxygen therapy devices, as these lack proven clinical efficacy, and therefore are not considered medically necessary.

Treatment/Application Guidelines:
For Members with the following diagnosis codes, Oxford will approve up to 10 treatment sessions upon initial precertification when the service is provided in an ambulatory surgery or hospital outpatient setting. All additional treatments require Medical Director review.

The following is also required:


A review for medical necessity is necessary for treatment lasting more than 2 months, regardless of the condition of the patient.
All requests for therapy for a condition not included on the list of diagnoses below require Medical Director review.
All treating physicians are qualified and credentialed by the hospital (in which HBO therapy is being performed) in hyperbaric medicine and the management of acute cardiopulmonary emergencies (including the placement of chest tubes).
Office notes from the prescribing and the treating physician are required when a Medical Director review is indicated.
Payment Guidelines:


Applicable ICD-9 Codes Description
039.0-039.1, 039.2
039.4, 039.8 Actinomycotic infections
040.0 Gas gangrene
444.21 Arterial embolism and thrombosis of arteries of the upper extremity
444.22 Arterial embolism and thrombosis of arteries of the lower extremity
444.81 Arterial embolism and thrombosis of iliac artery
526.89 Osteoradionecrosis, jaw
728.86 Progressive necrotizing infections
730.10-730.19 Chronic osteomyelitis
902.53 Injury to iliac artery
903.01 Injury to axillary artery
903.1 Injury to brachial blood vessel
904.0 Injury to common femoral artery
904.41 Injury to popliteal artery
927.00-927.03
927.09-927.11
927.20-927.21
927.8-927.9 Crushing injury of upper limb
928.00-928.01
928.10-928.11
928.20-928.21
928.3
928.8-928.9 Crushing injury of lower limb
929.0, 929.9 Crushing injury of multiple and unspecified sites
958.0,999.1 Air embolism
986 Toxic effect of carbon monoxide
987.7 Toxic effects of hydrocyanic gas
989.0 Toxic effects of hydrocyanic acid and cyanides
990 Effects of radiation, unspecified / soft tissue radionecrosis
993.2 Other and unspecified effect of high altitudes
993.3 Caisson disease (Bends, decompression sickness, compressed-air disease, diver's palsy or paralysis)
996.52 Skin graft failure or rejection
996.90-996.99 Complications of reattached extremity or body part


Lower Extremity Diabetic Wounds
For Members with the following diagnosis codes*, Oxford will approve up to 10 treatment sessions upon initial precertification when:


The patient has type I or type II diabetes and has a lower extremity wound that is due diabetes (see applicable ICD-9 codes below), and
The patient has a wound classified as Wagner grade III or higher; and
The patient has failed an adequate course of standard wound therapy.
*In addition to the code for the wound, a code indicating the diagnosis of diabetes is also required. *1st ICD-9 Code 2nd ICD-9 Code Description
250.70 to 250.73 No 2nd code required Diabetes with peripheral circulatory disorder
250.80 to 250.83 No 2nd code required Diabetes with other specified manifestations
250.xx 707.10* Ulcer of lower limb, unspecified
250.xx 707.12* Ulcer of calf
250.xx 707.13* Ulcer of ankle
250.xx 707.14* Ulcer of heel and midfoot
250.xx 707.15* Ulcer of other part of foot, toes
250.xx 707.19* Ulcer of other part of lower limb

For the conditions listed below, Hyperbaric Oxygen is NOT Covered:

Non-covered ICD-9 Codes Description
Multiple ICD Encephalopathies, Anoxic brain injuries and Developmental Delays
Multiple ICD Systemic aerobic infection
Multiple ICD Organ storage
Multiple ICD Arthritic disease
037 Tetanus
038.3 Anaerobic septicemia
280
285.1 Blood loss anemia
282.60 Sickle cell anemia
294.0
331.0
331.1
332 Nonvascular causes of chronic brain syndrome (Pick's disease, Alzheimer's disease, Korsakoff's disease).
340 Multiple Sclerosis
348.5 Acute cerebral edema
410.00-412 Myocardial infarction.
429.2
430-438 Acute or chronic cerebral vascular insufficiency.
440.23
440.22
443.0 - 443.9 Chronic peripheral vascular insufficiency
454.0, 454.1, 454.2 Venous stasis ulcers
491
492
492.8 Pulmonary emphysema
570 Hepatic necrosis.
707.00 Decubitus ulcer, unspecified site
707.01 Decubitus ulcer, elbow
707.02 Decubitus ulcer, upper back
707.03 Decubitus ulcer, lower back
707.04 Decubitus ulcer, hip
707.05 Decubitus ulcer, buttock
707.06 Decubitus ulcer, ankle
707.07 Decubitus ulcer, heel
707.09 Decubitus ulcer, other site
707.1
707.8
707.9 Cutaneous ulcers
785.51 Cardiogenic shock
797 Senility
947.0
947.1 Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency.
949 Skin burns (thermal)
V42.0-V42.9 Organ transplantation


Covered CPT/HCPCS Code Description
99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session
C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval


Non-covered HCPCS Codes Description
A4575 Topical hyperbaric oxygen chamber, disposable
G0167 Hyperbaric oxygen treatment not requiring physician attendance, per treatment session


References:


ECRI Hotline Response: Hyperbaric Oxygen Therapy for Chronic Wounds, Updated 11-12-2002. Retrieved 4-30-2003.

Medicare Coverage Issues Manual. 35-10- 35-13.

ECRI Hotline Response: Hyperbaric Oxygen Therapy for Chronic Wounds. November 12, 2002,. Retrieved 4-30-2003

The New England Journal of Medicine, June 20, 1996, Volume 334, No. 25.

Diabetes Care 2000, October; 23(10): 1551-5.

Ann Vasc Surg 1996, November, 10(6): 558-62.

Medicare Legal Review August 13, 2003.

Empire Medicare Services - New York. "Hyperbaric Oxygen Therapy." Policy number MED#125r1. Retrieved July 16, 2003.

Empire Medicare Services - New Jersey. "Hyperbaric Oxygen Therapy." Policy number Z-3G. Retrieved October 21, 2003.

Empire Medicare Services - New York (Intermediary). "Hyperbaric Oxygen Therapy." Policy number IM001A02. Retrieved July 16, 2003.

Empire Medicare Services - The Medicare News Brief - New Jersey & Downstate New York (Part B). "Coverage of Hyperbaric Oxygen (HBO) Therapy for the Treatment of Diabetic Sounds of the Lower Extremities." MNB-2003-2, February/March 2003. Retrieved July 16, 2003.

Empire Medicare News Update. "Coverage of Hyperbaric Oxygen (HBO) Therapy for the Treatment of Diabetic Wounds of the Lower Extremities." MNU-2003-9, September. Retrieved October 21, 2003.

Medicare Program Memorandum (Intermediaries/Carriers). "Coverage of Hyperbaric Oxygen (HBO) Therapy for the Treatment of Diabetic Wounds of the Lower Extremities." Transmittal AB-02-183. Retrieved July 16, 2003.

Medicare Program Memorandum (Intermediaries/Carrier). "Clarification Regarding Coverage of Hyperbaric Oxygen (HBO) Therapy for the Treatment of Diabetic Wounds of the Lower Extremities." Transmittal AB-03-102. Retrieved October 21, 2003.

CMS National Coverage Analysis (NCA). "Hyperbaric Oxygen Therapy for Hypoxic Wounds and Diabetic Wounds of the Lower Extermities. #CAG-00060N.

Hyperbaric Oxygen Therapy for Brain Injury, Cerebral Palsy and Stroke. Summary, Evidence Report / Technology Assessment: Number 85. AHRQ Publication Number 03-E.49, September 2003. Agency for Healthcare Research and Quality, Rockville MD. http://www.ahrq.gov/clinic/epcsums/hyposxum.htm
Effective Date: January 1, 2005

[ladycolorado]

here is a site for the poor:http://www.needymeds.com/ (LC).