Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decubitus ulcer
Treatment: durable medical equipment (DME) (A575 x 96), oxygen chamber device
The insurer denied coverage for durable medical equipment (DME) (A575 x 96), oxygen chamber device.
The denial is overturned.

This is the case of a young adult with a past medical history of intellectual disability, cerebral palsy, chronic respiratory failure, decubitus ulcer in the ischial area, decubitus ulcer in the sacral region, diabetes, epilepsy, gastrostomy tube dependence, and Lennox Gastuat syndrome. As reported, she has a left buttock wound and sacral, coccyx wound reopened stage 2. She denied fever, and the ischial ulcer was stable and new right posterior shoulder unstageable, left hip evolving stage 2 hip wound using Santyl stage 2. The provider noted that the patient had a urinary tract infection (UTI) last month and had recent admission for pneumonia. The patient did not use EO2 (innovative wound care company) that week and was using it now with Prisma and Santyl with alginate for depth. The provider noted that wounds had been better with VAC (vacuum-assisted closure), but the patient had a leak and possible accident with stool contamination of wound. The patient did have Dakin's applied wet to dry without the VAC for a week with much improvement. The patient presented to the office for care of the left buttock wound. The assessment was a left ischium buttock wound, stage 4, stage 4 left ischial ulcers, left hip stage 3. The patient is on EO2/ alginate, using hydrofera blue and Santyl on deeper wounds with good response and Santyl alginate on others. The sacral stage 2 reopened and using Santyl alginate EO2. The provider noted that EO2 was used for 3 months with wound improved, clean and pink.

The patient was seen previously for the wounds for which tissue analytics were performed for the left hip wound. The plan was alginate, foam adhesive, Santyl collagenase, soap and water daily. The patient was seen prior for her left hip, sacral and ischial ulcer. It was noted the patient was back on EO2. In a prior visit, the provider noted the patient was seen again for the left hip, sacral and ischial wounds. The patient was seen prior for the same treatment.

The patient's mother is appealing. In an appeal letter, she stated that the patient has been using the oxygen patches. They were approved by the prior insurance and the patient's wounds continue to improve.

Frykberg et al noted in "A Multinational, Multicenter, Randomized, Double-Blinded, Placebo-Controlled Trial to Evaluate the Efficacy of Cyclical Topical Wound Oxygen (TWO2) Therapy in the Treatment of Chronic Diabetic Foot Ulcers: The [topical wound oxygen] TWO2 Study" in Diabetes Care that "topical oxygen has been used for the treatment of chronic wounds for more than 50 years. They noted in at least for diabetic ulcers that "this sham-controlled, double-blind randomized controlled trial demonstrates that, at both 12 weeks and 12 months, adjunctive cyclical pressurized TWO2 therapy was superior in healing chronic diabetic foot ulcers (DFUs) compared with optimal standard of care (SOC) alone". They did point out that the literature is limited in general. 

Thus, there is literature to support continuous diffusion of oxygen for wound healing and in this case, it appears to have been useful and successful for this patient.

Therefore, based upon the clinical information provided to me, the reviewer does feel that the coverage for the durable medical equipment, oxygen chamber device should be approved given that it has been used in the past in this patient. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for durable medical equipment (DME) (A575 x 96), oxygen chamber device services is substantiated.