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

Physician 1:  This patient is a 54-year-old male diagnosed with Crohns disease that has recurrent pouchitis and severe perianal lesions. He has failed 6-mercaptopurine (6-MP), mesalamine (5-ASA) compounds and biologics including Remicade and Humira. The patient has been on high doses of oral steroids and has required frequent inpatient treatment.  He has had an overall poor response to medical management.  The patients provider requested authorization for hyperbaric oxygen therapy indicating it has provided some symptom relief for the patient in the past. The health plan has classified this treatment approach as investigational and denied the request for authorization and coverage. The patient has severe, refractory Crohns disease as evidenced by recurrent pouchitis and significant perianal involvement. Existing data has not established that hyperbaric oxygen therapy will result in lasting improvement or prevent future exacerbations of his condition. Surgical intervention may be the only alternative at this juncture.  As such, 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 54-year-old male with Crohns disease. He has failed several of the more standard treatment approaches, and has frequent flares of his disease with pouchitis and perianal and pelvic pain. His provider reports some benefit from hyperbaric oxygen therapy in the past and a request for authorization was submitted to the Health Plan. The Health Plan considers this therapy experimental/investigational and denied the requested authorization.The Health Plan is correct that the proposed therapy is considered experimental. There have been some small studies on HBO therapy for Crohns disease, but there are no prospective double-blind studies in peer-reviewed journals that demonstrate that this approach is clearly beneficial in treating Crohns patients. 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 54-year-old male with a history of Crohns disease who is status post proctocolectomy with ileoanal pull through approximately five years ago. He has recurrent episodes of pouchitis for which he has been hospitalized multiple times and treated with IV steroids, Remicade and Humira. The patient was intolerant of 6-MP earlier, but has now also become intolerant to Remicade and Humira. Of late, his pouchitis flares any time he is tapered off of prednisone. The patient is currently being treated with metronidazole, Viracil #3, prednisone, 60mg daily, and Norco for pain. Hyperbaric oxygen (HBO) therapy has been associated with some improvement in his symptoms of anorectal pain, and pouchitis. The patient has requested authorization for a repeat course of HBO therapy. The Health Plan denied the request citing the experimental nature of the therapy.The patient suffers from severe anorectal and pelvic pain secondary to recurrent flares of pouchitis. He has become refractory or intolerant to standard medical therapies. Perineal involvement and pouchitis are common and distressing conditions with Crohns disease and the pathogenesis remains unclear. It is believed that local ischemia and secondary anaerobic infection may play a role. Recent reports suggest that HBO therapy is effective in the healing of perianal disease in some Crohns patients refractory to medical therapy. Although it is not fully understood why HBO works in perianal Crohns disease, some possible mechanisms include enhancement of the direct bacterial killing activity of leukocytes, enhanced fibroblast replication or enhanced collagen synthesis. Many of the study subjects healed partially or completely with HBO therapy. As conventional therapy has proven ineffective, 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.