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

Physician 1: The patient is a 75-year-old male with a long history of a non-healing diabetic foot ulcer on the plantar left foot. His provider reports standard treatment modalities have been ineffective. The patients provider further states the patient has benefited from use of hyperbaric oxygen therapy. The Health Plan has denied coverage for hyperbaric oxygen therapy on the basis it is considered experimental for treatment of the patients condition. Review of the scientific evidence reveals there have been few trials involving hyperbaric oxygen therapy for diabetic ulcers. There is insufficient evidence hyperbaric oxygen therapy is superior to standard treatment modalities. In general there is limited quality data on the benefits of many of the therapies for diabetic ulcers. However, Regranex in sub-atmospheric oxygen dressing has been shown to be effective. The submitted records provide very little evidence a standard program of therapy was employed before hyperbaric oxygen therapy. It appears the patient used betadine dressing frequently; betadine does not promote healing of diabetic ulcers and may actually impede healing. Finally, hyperbaric oxygen should only be used as a supplement to other methods. Therefore, 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. The Health Plans denial should be upheld.Physician 2: The patient is a 75-year-old man with diabetes and a diabetic foot ulcer that has been treated with offloading local wound care, Regranex, and topical oxygen therapy. There is no objective documentation of adequacy of blood flow in the submitted clinical information. The patients wound is currently near-healed and the last measurement recorded in February 2005 was 3 mm. As of March 2005, there was a minimal callus and the patients provider was planning on orthotic casting for pressure reduction to prevent recurrence in the future. The patient is currently on local wound care. A request has been made for hyperbaric oxygen therapy, which the Health Plan has denied.The patient has a chronic diabetic foot ulcer that is near-healed. There is insufficient evidence of the role of hyperbaric oxygen therapy in the treatment of diabetic ulcers. Thus, hyperbaric oxygen therapy is an experimental therapy for treatment of patients such as this patient. The role of the proposed therapy still needs to be defined. Furthermore, given that the wound is near-healed, it appears the patient can be appropriately treated with conventional therapies. Therefore, 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. The Health Plans denial should be upheld.Physician 3: The patient is a 75-year-old male who has requested authorization and coverage for hyperbaric oxygen therapy for the treatment of a non-healing ulceration of the left foot. The patient has had standard therapy including antibiotics, offloading, wet to dry dressings, and Regranex. The Health Plan has denied the patients request for hyperbaric oxygen therapy indicating the efficacy of the requested therapy has not been established.Review of the relevant literature reveals little evidence of the benefit of hyperbaric oxygen therapy for the treatment of diabetic ulcers. There is no significant consensus of support for this treatment intervention. The patient is likely to receive greater benefit from standard therapy than from hyperbaric oxygen therapy. Therefore, 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. The Health Plans denial should be upheld.