Diagnosis: Diabetes, osteomyelitis, non-healing diabetic foot ulcer

Treatment: Hyperbaric oxygen therapy

The insurer denied the hyperbaric oxygen therapy. The denial was reversed.

The patient is a female with a past medical history of diabetes mellitus and asthma, who presented to the Emergency Department with complaints of left toe pain and swelling following an injury. The patient was treated with intravenous antibiotics, surgical debridement, and wound care for treatment of septic arthritis and osteomyelitis of the middle and distal phalanx of left second toe. At issue is the medical necessity of hyperbaric oxygen therapy full body chamber for treatment of non-healing diabetic foot ulcer. Hyperbaric oxygen therapy (HBOT) has been used to treat several medical conditions and currently has Food and Drug Administration (FDA) approved indications for certain types of infections including gangrene, skin/bone infections and non-healing wounds such as diabetic foot ulcer.
Medicare covers HBOT for diabetic wounds of the lower extremities, if the following apply: Type 1 or Type 2 diabetes have a lower extremity wound that is due to diabetes; wound classified as Wagner grade III or higher; failed an adequate course of standard wound therapy.
According to medical records, the patient has Wagner grade III since underlying osteomyelitis has been confirmed on MRI. Although one can argue that the injury ("hot oil spilled on foot") initially caused this infection, subsequent complications, including non-healing ulcer and osteomyelitis, were clearly exacerbated by the patient's underlying diabetes mellitus. Based on these findings, the patient fulfills the above three criteria for hyperbaric oxygen therapy coverage.

The carrier's denial of Hyperbaric Oxygen therapy full body chamber is reversed. The medical necessity is substantiated.