Thank you to Dr. Helen Gelly for providing this guest post about Medicare denials for radiation proctitis. –Caroline
Why are Medicare charges for hyperbaric oxygen therapy (HBOT) denied when treating radiation proctitis?
National Coverage Decision (NCD) 20.29 (Hyperbaric Oxygen Therapy) supports Medicare coverage of radiation-induced injury in the pelvis under the definition of soft tissue radiation necrosis. However, Medicare may deny charges for HBOT in the treatment of radiation proctitis unless the diagnosis of soft tissue radionecrosis is also linked and precedes it. Radiation to the pelvis involves two main areas, bladder and rectum. Radiation damage to the bladder has an assigned CPT code in the code list approved by Medicare for HBOT. The code for Radiation proctitis (ICD-10-CM K62.7) is NOT on the list of approved codes for HBOT. Although commercial carriers uniformly cover this indication and the American Society of Colon and Rectal Surgeons has listed hyperbaric oxygen therapy as an accepted therapeutic modality in the treatment of radiation proctitis, Medicare may not cover it, depending upon the coding.
The Medicare Administrative Carrier (MAC) First Coast took “bowel” out of the Local Coverage Determination (LCD) language for HBOT. Novitas left in in. Although that LCD has been retired, it is possible that their approach to coverage will not change.
If radiation damage to the bladder is covered, why not to the bowel?
Part of the problem is that bowel is not considered “soft tissue” according to the medical definition of soft tissue which includes muscle, fat, fascia, tendon, ligaments, etc. It is perhaps unfortunate that the Undersea and Hyperbaric Medical Society (UHMS) identified all tissues that are not bone (hard) as “soft” when crafting statements about the effectiveness of HBOT in this condition. While bowel would seem to be a “soft tissue” (since it is not bone), CMS still uses the literal meaning of soft tissue as a potential reason to deny HBOT.
To have a hope of payment, the physician must document if possible, fibrosis of the anterior abdominal wall. If the patient had external beam radiation, then fibrosis may be evident on the abdominal wall. The physician should ask very specific questions about urinary symptoms since radiation damage might have affected the bladder. The problem is that patients focus on the problems which concern them the most and if their most life altering problem is radiation proctitis, they might fail to mention radiation cystitis. CMS covers radiation cystitis without hematuria, so be sure to ask about bladder symptoms. If present along with radiation proctitis, it would be best to code the condition as radiation cystitis (N30.4X). Remember that K52.0 (Gastroenteritis and colitis due to radiation) and K62.7 ( radiation proctitis) have never been listed codes.
You should appeal denials for radiation proctitis and send a copy of the ASCCRS guidelines with the appeal. You may not be successful until you get (virtually) in front of an administrative law judge in a year or so. Remember that CMS is supposed to pay for “standard of care,” and the standard of care for radiation proctitis and enteritis is HBOT.
The following links might be useful in establishing the “standard of care” for radiation proctitis when you appeal: