Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1:  The patient is a 69 year old female that was diagnosed with breast cancer in March 1995. She was treated with lumpectomy and radiation. Subsequently, she was diagnosed with a rectal tumor in October 1995 and underwent surgery followed by chemotherapy and radiation therapy. The patient has developed radiation necrosis with soft tissue groin and perineal breakdown of a chronic nature such that blood transfusions and laser therapy have been necessary. Her provider has recommended hyperbaric oxygen (HBO) therapy for treatment of the patients non-healing wound. The Health Plan has denied authorization for the proposed therapy on the basis that HBO therapy is considered investigational.Review of the submitted clinical evidence indicates this patient has soft tissue radiation induced wounds, which are chronic in nature with evidence of bleeding severe enough to merit blood transfusion. One remaining treatment option may be flap reconstruction of the radiation-damaged tissue. However, this is a more invasive procedure than HBO therapy and HBO therapy does have the potential to correct the patients condition. As such, it is clinically appropriate to pursue HBO therapy in this case to possibly avoid surgical intervention.Based upon the information set forth above, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Physician 2:  The patient is a 69-year-old female with a history of rectal cancer who underwent radiation and chemotherapy. The patient has dermatitis and hemorrhagic proctitis consistent with soft tissue radiation necrosis. Diagnosis was made clinically and her provider has recommended treatment with hyperbaric oxygen (HBO) therapy due to severe pain and limited alternative therapies. The Health Plan has denied coverage for HBO therapy on the basis that it is considered investigational for treatment of the patients condition.The patient has soft tissue radiation necrosis based on clinical symptoms and physical examination as well as having a history of an irradiated site. Based on the case studies and relevant retrospective analysis as well as clinical experience, there are no conservative alternatives (e.g., ointments, dressings, etc.) that are likely to alleviate this patients symptoms. HBO therapy is an appropriate intervention under these circumstances and resolution is often seen after 30 HBO treatments. Accordingly, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3:  The patient is a 69 year old female that has a chronic wound in the groin after radiation she received for treatment of rectal cancer. She suffers from pain. The wound has been treated with creams and special cleansing. Her physician is recommending a trial of hyperbaric oxygen therapy. The Health Plan has denied authorization for the requested therapy stating it has not been medically proven to be more beneficial than alternative therapies.There is insufficient evidence of the role of hyperbaric oxygen therapy in the treatment of a wound secondary to radiation therapy. The use of hyperbaric oxygen therapy is not the standard of care for the treatment of patients such as this patient. The role of the proposed therapy in this clinical setting has yet to be defined. For these reasons, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.