We may be the first, but we will not be the last

Friday’s Featured Friend and Guest Blogger is none other than Helen Gelly, MD, FUHM, FACCWS, UHM/ABPM.

When it rains, it pours. There seems to be no end to the rain clouds on the horizon for hyperbaric medicine. But HBO is not the only specialty at risk. CMS (Medicare) through the local intermediaries (MACs) are beginning to tell physicians how they should be practicing, defining parameters for dosing and frequency, and patient selection. This started with Novitas when they published their local coverage decision draft policy, last year, was copied by First Coast, and now by Noridian. Due to the coverage are of these three MACs, over 60% of covered Medicare beneficiaries will be affected by the language in these LCDs. When multiple MACs are copying the same LCD, it becomes a NATIONAL issue.

In times past, NCDs and LCDs were written, but common sense guided their interpretation and what was right for the patient was covered. In today’s environment, these documents are being taken literally; there is very little “spirit of the law” in play. Therefore, we must read each line and address whether or not we can actually document what is required. Much more insidiously, the current Noridian draft LCD addresses HOW physicians need to practice. This is unprecedented in my experience. The ramifications are far-reaching and ominous.

As an example, let us look at hip replacements. Depending upon the age of the patient, the body habitus and the activity level of the patient, an anterior, posterior or lateral approach may be used. Imagine a LCD that tells orthopaedic surgeons that they may ONLY use the posterior approach. Or an Infectious disease specialist that they MUST give 1000 mg of IV Vancomycin every 12 hours to a patient for endocarditis, with no discretion allowed for age, body weight or concomitant renal dialysis?

Crazy, right????

Let us look at the Noridian LCD for a few of these pearls.

If you were to treat carbon monoxide patients that are alert but symptomatic, could they be treated safely while in the Emergency Room and then discharged? Noridian say NO, NO, NO, they MUST be inpatients.  How silly is that? When you look at the cost of the inpatient DRG data from 2011 for the group with the diagnosis of carbon monoxide, the average cost of patient with major complications is $11, 607. It is $5,524 for an admission without major complications. Under the current outpatient pricing, a course of three hyperbaric treatments for an outpatient carbon monoxide patient would be about $1650.  Why would you incur the additional cost of care when it is totally unnecessary? Let the doctor decide who is sick enough to be admitted.

If you were to treat an acute arterial thrombosis ( many times that presents as critical limb ischemia over a few day period of time) you would not be able to have the interventionist do the thrombectomy in an out-patient setting, and have the patient receive adjunctive HBOT because Noridian says the MUST be inpatients.

If you cannot find the actual documentation that confirmed prostate cancer and the subsequent radiotherapy note which was done 10 years ago (many states only require medical records to be held for 7 years), should you be denied the hyperbaric oxygen claims for radiation cystitis? Are physicians and patients in the habit of lying about cancer and its treatment? Must we produce proof of cancer and radiotherapy, despite the fact that everyone including the patient states they have had this problem?

Should you be told what treatment pressures to treat at, and then be denied if a medical review says : Dr. Dotherightthing, we are not going to pay you because you did not treat that gas gangrene at 3.0 ATA TID.

You say: They were on high dose steroids, had a seizure disorder and we could only do 2 treatments that day. They say: We are sorry but your practice did not follow our guidelines. And by the way, we know that we are asking you to do 3 treatment in the first 24 hours (translating into > than 12 segments of which we will only pay 5) but you only managed to do 2 so……HOW CAN THEY TELL US HOW TO PRACTICE???? Does a MAC have the right to determine doses, duration, and frequency of a drug?

If you had a pregnant woman with necrotizing fasciitis and she needed HBO you will not get paid, because Noridian states that this is contraindicated. If she has a vascular air embolism, she will be denied, because without a grain of evidence, Noridian, First Coast and Novitas decided that pregnancy is a contraindication to hyperbaric therapy except in the case of carbon monoxide poisoning. To make the parameters even more draconian, there must be documentation of fetal distress. However, they have not told us how to determine fetal distress in the first trimester. I suspect that is because no one has a way of doing that.

You might wonder why pregnancy treatment parameters are even relevant in the Medicare population. Medicare also covers all people on dialysis and on disability without regard to age. Since many commercial insurance carriers use Medicare guidelines to guide their medical policies, what start is Medicare does not stay in Medicare.

Without a doubt, in this era of increasing scrutiny, it is reasonable for some parameters regarding GUIDELINES for therapy, and potential treatment caps. However, it is not reasonable for a MAC to define dosing parameters of a drug. Pre-defining the drug dose for a patient is not good medicine and fraught with medico-legal ramifications. Taking it a step further, Noridian, Novitas and First Coast are requiring inpatient admissions for a variety of diagnoses. This flies in the face of the trend towards outpatient care and removes critical thinking from the equation.

Leave the practice of medicine to the physicians who are treating the patient.

It is vital that ALL hyperbaric physicians who see patients write to express their concerns about these changes. Make your opinions and comments heard at :  policyb.drafts@noridian.com,for what is raining down on HBOT will soon be raining down on other specialties.

Read more about this issue at: https://www.uhms.org/call-to-action-noridian-draft-policy-dl36686-is-currently-in-comments-phase-until-aug-8-2016.html

Meet My Guest Blogger:  Helen Gelly, MD, FUHM, FACCWS, UHM/ABPM

Dr. Gelly has been involved in hyperbaric medicine and wound care since 1991. Past positions have included Medical Directorships at academic and community hyperbaric medicine and wound care programs. She started a non-hospital affiliated hyperbaric medicine center which was one of the first UHMS accreditated centers. She has been actively involved in billing and reimbursement issues for both facilities and physicians. Until recently, she was the Medical Director of Hyperbaric Physicians of Georgia, a group of physicians dedicated to the practice of hyperbaric medicine and wound healing, with 5 subspecialty boarded physicians in its membership. In addition to lecturing nationally on hyperbaric medicine and wound healing for many years, she was the president of the Gulf Coast Chapter of the UHMS from 2005-2007. Currently, she serves as the Emeritus Medical Director of Hyperbaric Physicians of Georgia, and as C.E.O. for HyperbaRXs.



Caroline Fife, MD

I’ve got a NEW Facebook Page – be sure to follow me there too!

Twitter/CarolineFifeMD Facebook/CarolineFifeMD  |  LinkedIn/CarolineFifeMD