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Safety/Technical

Questions pertaining to safety and technical information. Open to the public.

cancers currently being treated with 5FU gel. We were wondering if there would be any contraindication for starting HBO treatments..
Published: 11 March 2021

cancers currently being treated with 5FU gel. We were wondering if there would be any contraindication for starting HBO treatments..

Posted: 3/15/2021


Q: 
Cancers currently being treated with 5FU gel. We were wondering if there would be any contraindication for starting HBO treatments.


 A:
5FU when used topically for precancerous skin conditions can cause pretty brisk skin reaction with peeling and sloughing much like a bad sunburn. My belief is that HBO given while the topical 5FU is still on the skin and not either been evaporated or soaked in might make the reaction a bit more brisk But the systemic absorption will be very little and systemic symptoms should not be exaggerated. When taken by mouth intravenously or a precourser is taken orally, it can cause brisk diarrhea. However, topically used that should not be a problem.

Under Select problem wounds- small vessel disease , are there any diagnosis that can be used for arterial patients who have been revascularized, respond to an oxygen challenge, but are not diabetic wounds? Any advice would be greatly appreciated.
Published: 26 April 2021

Under Select problem wounds- small vessel disease , are there any diagnosis that can be used for arterial patients who have been revascularized, respond to an oxygen challenge, but are not diabetic wounds? Any advice would be greatly appreciated.

Posted: 5/4/2021


Q: 
Under Select problem wounds- small vessel disease , are there any diagnosis that can be used for arterial patients who have been revascularized, respond to an oxygen challenge, but are not diabetic wounds? Any advice would be greatly appreciated.

 

A:

From Helen Gelly, MD

If Medicare, then they would have to have arterial thrombosis/gangrene ( I do not think they need to have claudication personally) documented. Microvascular disease is not addressed in the CMS guidelines. 

However, Anthem has the following guidelines: 

  1. Acute peripheral arterial insufficiency; or
  2. Chronic non-healing wounds in the following situations:
    1. Diabetic lower extremity wounds, when the following criteria are met:
      1. As a component of diabetic ulcer management (for example, careful attention to infection control, aggressive surgical debridement, evaluation and correction of vascular insufficiency, extremity offloading, improving glycemic control, and when applicable, encouraging smoking cessation); and
      2. Wagner grade III or higher wound severity; and
      3. Wound has not responded to 30 days of appropriate conservative treatment and which show continued response when evaluated at 30 day intervals; or
    2. Arterial insufficiency ulcers in individuals with persistent hypoxia despite attempts at increasing blood flow or when wound failure continues despite maximum revascularization; or
    3. Pressure ulcers in the following situations:
      1. Postoperative support of skin graft or flaps showing evidence of ischemic failure; or
      2. In the field of previous irradiated area for pelvic or perineal malignancies; or
      3. When progressive necrotizing soft tissue infection or refractory osteomyelitis is present; or
    4. Venous stasis ulcers when supporting skin grafting or flap reconstruction in individuals with concomitant peripheral arterial occlusive disease and hypoxia not corrected by control of disease; or

Aetna:

  • Acute peripheral arterial insufficiency (i.e., compartment syndrome) requiring emergent surgical intervention (e.g., surgical or catheter directed embolectomy or bypass surgery), with imaging documentation of embolus/thrombus (e.g., MR, angiogram)
  • Acute traumatic peripheral ischemia (including crush injuries and suturing of severed limbs) when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy

Humana:

  Humana members may be eligible under the plan for HBOT as adjunctive treatment for the following indications:

  • Acute peripheral arterial insufficiency (ALWAYS requires review by a medical director) with documentation of the following: 

o Operative report to confirm lysis/removal of clot/embolus; 

AND

o Vascular study that confirms vessel obstruction by clot/embolus and location 

So, the answer is it depends. 

 

From: John Feldmeier, DO

The S91 series in the ICD-10 manual is for foot wounds with various modifiers according to exact location and some specific etiologies, eg. laceration or post-amputation.
You would probably also want to add the diagnosis for arteriosclerosis of the extremities. These are in the I17 series with the appropriate modifiers. They have these for exact location and for gangrene or ulceration. The specific code for ulceration suggests to me that claudication also has to be present.

You have not been specific, and I don't think I can go beyond my general guidance. Obviously, you are probably hoping that there is a code for which the third-party carriers will pay for HBO2. I think the chances of that for a Medicare patient are very poor. If he has another insurance reviewing their indications or consulting them would be a good idea.

If it were me, I would get ahold of the surgical records from the bypass and see how the surgeon coded it for consistency.

If your question is whether the patient is likely to respond to treatment, in my experience they are likely to respond. However, during Caroline Fife's Presidency in 1999, Medicare or CMS now significantly reduced indications for hyperbaric oxygen. This reduction included peripheral extremity hypoxic and chronic ulcers from indications like collagen vascular disease caused ulcers and Buerger's disease. So, you are left with the dilemma: do you treat realizing that insurance is very unlikely to reimburse. Sorry I wish there was another way to code, but I don't know of any. You may be able to appeal to a medical director of the insurance co. If you do carefully explain the rationale of doing a TCPO2 after revascularization indicating the likelihood of small vessel disease that leads to continued hypoxia in spite of a successful vascular graft. Obviously, you will also need to explain the significance of the oxygen challenge.