CMS Expands Coverage Of HBO To Diabetic Foot Ulcers

By Gina DiGironimo, Production Editor

Beginning this month, the Centers for Medicare and Medicaid Services (CMS) will expand its coverage of hyperbaric oxygen therapy (HBO) to include the treatment of diabetic wounds in the lower extremities. According to the CMS, in order to qualify for this coverage, patients must have: type 1 or type 2 diabetes and a lower extremity wound due to diabetes; a wound that is classified as a Wagner grade III or higher; and have failed an adequate course of standard wound therapy. Caroline Fife, MD, says the expanded coverage is a “big step forward.” “It represents an understanding on the part of Medicare of the overwhelming data on the effectiveness of HBO in improving limb salvage in diabetic foot ulcers,” says Dr. Fife, a Clinical Associate Professor within the Department of Anesthesiology at the University of Texas Health Science Center. While Medicare and other insurers have provided coverage for HBO over the years to treat conditions ranging from necrotizing fasciitis and chronic bone infections to crush injuries, Dr. Fife says there was a lack of uniformity in coding across the various regional Medicare carriers. “As a result, in some regions, it was easier for wounds to be treated than in others,” recalls Dr. Fife. Now there is a specific code (HCPCS 99183) for using HBO to treat diabetic lower extremity wounds. Dr. Fife emphasizes that if patients are properly screened, HBO therapy can be a cost-effective option because it “prevents costly amputations.” The CMS notes that HBO will only be covered as an adjunctive therapy after all standard wound care treatment has failed to yield measurable signs of healing after a 30-day period. When using HBO therapy, you need to evaluate the wound every 30 days to ensure that it is healing properly. Also keep in mind that continued treatment with HBO will not be covered if there are no measurable signs of healing within any 30-day period of treatment, according to the CMS. Dr. Fife cautions that improved coverage may not improve the availability of treatment since the FDA-approved hyperbaric chambers are not commonplace. “An increase in coverage does not equal an increase in awareness of the benefits of hyperbaric therapy,” maintains Dr. Fife. Study Offers Mixed Results On Topical Oxygen Therapy In a somewhat related development, a new study by researchers at Ohio State University revealed that using topical oxygen therapy alone led to healing of difficult wounds in more than two-thirds of the 30 patients in the study. Researchers of the study, which was published in a recent issue of Pathophysiology, noted that acute traumatic and post-surgical wounds on the trunk, arms and hands showed a 75 and 100 percent healing rate respectively. However, lower extremity wounds did not fare as well in comparison. The study authors noted that only half of acute wounds on the legs and feet healed with topical oxygen alone. “While topical oxygen helps wounds heal, it alone may not be adequate for managing lower extremity wounds,” noted Dr. Chandan Sen, the lead author of the study, to However, he said that using topical oxygen “may be helpful” if one uses it adjunctively with other wound care modalities or surgery. The authors of the study applied topical oxygen therapy for 90 minutes a day over a four-day period, which was followed by three days of rest. According to the study, the duration of treatment ranged from 24 days to eight months. Many of the participants had at least one health condition such as cancer, an active infection or diabetes. The aforementioned CMS decision to expand coverage of HBO to lower extremity diabetic wounds does not apply to topical oxygen therapy. Dr. Fife says Medicare doesn’t pay for topical oxygen because there is not enough clinical evidence to support its use. “To date, no one has been able to show significant increases in tissue oxygen tension using any kind of topical oxygen,” explains Dr. Fife. In comparison, Dr. Fife points out that hyperbaric oxygen has been demonstrated to increase tissue oxygen levels to between 200 and 1000 mmHg using transcutaneous electrodes. She adds that a few early studies on topical oxygen showed that it actually made wound healing worse. Studies Reveal Shoe Size Dilemmas For People With Diabetes By Brian McCurdy, Associate Editor The question of whether diabetic patients wear shoes that are the correct size is one that has not been explored very often.

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