Straight Talk Tuesday

Tuesdays in the month of June, I’m offering some straight talk about a few of the MANY ways in which payment for hyperbaric oxygen therapy is going to change and FAST.  A huge change are new limits on Coverage for HBOT by Private Payers. Capital Blue Cross, Milliman and The Community Technology Assessment Advisory Board released HBO Guidelines or Medical Policy documents reclassifying many conditions/diagnoses approved by CMS for HBO therapy as either non covered, investigational or raised the level of severity before coverage would be considered. Blue Cross Blue Shield (BCBS) of Tennessee removed all HBOT indications except diabetic foot ulcers, arterial gas embolism, carbon monoxide, severe anemia and decompression sickness. These changes were based on an “evidence” review by Milliman.

BCBS California made the following investigational: Necrotizing fasciitis, compromised grafts,  radiation induced injury to the head and neck (although they approved ORN and Marx protocol),

Central Retinal Artery Occlusion (CRAO), thermal burns, acute peripheral arterial insufficiency, and intracranial abscess. Why does this matter A LOT? Because there is increasing adoption of Medicare “advantage plans” over traditional Medicare. These plans are supposed to mirror Medicare national coverage policy but they seem to be adopting the guidelines of the private payer.

What’s your plan for the shrinking list of indications for which HBOT is covered? Dr. Enoch Huang and members of the UHMS Reimbursement and Education committees began developing Clinical Practice Guidelines (CPGs) for all the HBO indications using the GRADE methodology. The Diabetic foot ulcer CPG is now complete and has been published in Undersea and Hyperbaric Medicine. We need more funding for this process and we need to get these evidence based guidelines out quickly so that we have something to use in response to the increasing number of “evidence reviews” which often selectively ignore favorable HBOT data.