The Centers for Medicare & Medicaid Services (CMS) has implemented a prior authorization model for non-emergent hyperbaric oxygen therapy in Illinois, Michigan, and New Jersey. It is the position of CMS that it can reduce spending on HBOT services while maintaining or improving quality of care by ensuring that services are provided in compliance with Medicare coverage and payment rules before the claims are paid.
Helen Gelly and I will have a brief update about this in the October issue of Today’s Wound Clinic. However, I thought I’d list just a few reasons for pre-authorization denial so far:

  • For a patient with a failing FLAP, HBOT was denied because the tissue at risk was not a skin graft, (“flap” is not in the language of the NCD)
  • For DFU patient, no documentation of 30 days of standard wound care (this includes off-loading at each visit)
  • For a DFU patient, no documentation of vascular screening ( physical exam in insufficient) or documented action to correct PAD if present
  • In a DFU patient, if action was taken to correct PAD (as a result of abnormal vascular screen), a subsequent vascular screening was needed to determine response to vascular intervention
  • In a DFU, Hemoglobin A1C not done at time of initial visit, and then after 30 days.

There are some worrisome reports that some patients have been denied for late effects of radiation because they did not have diabetes, suggesting conflating of criteria for DFUs and other HBOT indications. In any case, rumor has it that the denial rate is running more than 50% and could be 80%. How do you think that is going to affect “wound care as a business”?09:0