I support this worthwhile and needed legislation with personal knowledge, after being Director of Hyperbaric Medicine and Wound care at the two largest hospitals in Corpus Christi. In about 1983, Memorial Hospital, the former city county hospital for Nueces County was one of 11 hospitals in the United States to treat the Multiple Sclerosis patients free of charge for a period of one year, on an investigational protocol. In all, I have treated about 200 MS patients during the past 18 years with very gratifying results. My experience in acute strokes, CP, ALS and other neurological diseases is limited, but, it is pretty obvious to me that there has got to be benefits if you understand basic anatomy, physiology, biochemistry, and pathology and also have the knowledge of how hyperbaric oxygen works!

I am a retired Flight Surgeon, and Submarine and Diving Medical Officer and have been working with HBO for the past 32 years.

Sincerely,

Billy J. Blankenship, DDS, MD

Captain, Medical Corps, US Navy (Ret)

Corpus Christi, Texas 78418

bjblanks@aol.com

Reimbursement for HBOT in Cerebral Palsy

I have been preparing for my final appeal for reimbursement for HBOT. This has been a 2-year battle. Twice I have appeared before a panel to state my case. Both times they tabled my case because they needed to review all the information I submitted or get an outside opinion.

I received a letter from Blue Cross Blue Shield again, stating their denial of payment based on the latest information I submitted. This is what they said:

1) There is no sound scientific evidence that hyperbaric oxygen is effective in the treatment of cerebral palsy.

2) We consider procedures or services to be investigational if they are under study or in clinical trial to evaluate toxicity, safety, or efficacy for a particular diagnosis or set of indicators. The prevailing opinion within the appropriate specialty of the United States medical profession is that the service or supply needs further evaluation for a particular diagnosis or set of indications before it is used outside clinical trials or research settings.

3) BCBS’s medical policy is based on the review of nationally accepted guidelines and standards of practice, BCBS Association technical evaluations, Peer-reviewed, published scientific literature, consultations with experts in the specific policy area, including practicing physicians and information from appropriate government regulatory bodies.

I am asking for those of you “in the know” how I should respond to the above. My plan of attack is to challenge them that they do pay for services that lack the double-blind peer reviewed criteria. Also I am going to try and say that I am simply using HBO as an off label use.

I believe the argument is simply, does BCBS pay for things that lack the double-blind peer reviewed criteria? (Yes) and on what basis are services paid for or denied?

Anyone, who has any ideas or help, please contact me. Here is a fitting quote from Voltaire “It is dangerous to be right in matters in which the established authorities are wrong”.

I believe the established authorities are wrong.

Enjoying the Journey,

Kevin Bals

73 Spring Lake Garden Court

Spring Lake, NJ 07762

Phone: 732-449-1244

kbals@rocketmail.com

I am an emergency physician in NY and I have two questions:

Is the antabuse effect of flagyl significant in HBOT?

I saw a study last year or so that concluded that there was probably no benefit to HBOT in CO poisoning; have there been any more definitive studies?

Thanks, Ronald Shaw

RONALDPSHAWMD@aol.com

Dear Dr. Shaw:

Although metrondazole has an antabuse effect in a patient drinking alcohol, there is no evidence in the literature that it has an effect of inhibition of superoxide dismutase production like antabuse does. In fact, one article suggests that metronidazole has an anti-oxidant effect by improving neutrophil response to reactive oxygen species. There is no scientific data I know of to state that it is either hazardous OR safe to use in the hyperbaric environment. Common usage would suggest, however, that a fair number of patients with metronidazole-sensitive infections are probably treated in hyperbaric chambers around the country while taking the drug. I would welcome comments from anyone who has seen an oxygen toxicity related event that could be attributed to metronidazole.

And now for the $64,000 question. I assume that your comments about the carbon monoxide efficacy are prompted by the press that Scheinkestal’s article received in the Medical Journal of Austraila. That article prompted a significant response not only in the journal where it was published, but in others as well. Multiple faults were found in the methodology of the study, grouping of patients, and psychometric testing, among other things.

There was a recent Cochrane Review of hyperbaric oxygen for carbon monoxide poisoning. Their conclusion is that “there is no evidence that unselected use of HBO in the treatment of acute CO poisoning reduces the frequency of neurological symptoms at one month. However, evidence from the available randomized controlled trials is insufficient to provide clear guidelines for practice. Further research is needed to better define the role of HBO, if any, in the treatment of carbon monoxide poisoning.”

This is, I believe, a fair statement. The medical community is divided between those of us (mainly hyperbaricists) who feel that HBO is beneficial [the believers], and those who feel it is not useful [the heritics]. The problem, as evidenced in a survey published in Undersea & Hyperbaric Medicine a few years ago, is that even where HBO treatment is performed, there is tremendous variability in the time and pressure used for treatment. Some programs used their standard wound protocol (2.4 ATA for 90 minutes), some used the US Navy Treatment Table 5, and some used a so-called CO Treatment table (3 ATA for 80 minutes – or some other variable of time). Hyperbaric programs also had widely different thresholds to determine when a patient received treatment with so much discrepancy in the hyperbaric treatments used, it is obvious that amassing a large amount of treatment data is difficult.

A more recent article, although biased towards hyperbarics, stated, “hyperbaric oxygen remains an established, although inconclusively proven, treatment option.”

My personal feeling is that, as our hyperbaric research community further delineates the mechanisms of cellular toxicity and other actions of CO and standardizes the treatment (time/pressure), we may have a better handle on the complete picture. For now, based on what I know and the results I see, I will continue to treat my severely poisoned CO patients with HBO, (acknowledging that there is no clearly accepted definition of ‘severely’ in our literature).

Thomas M. Bozzuto, D.O. President, American College of Hyperbaric Medicine

Medical Director, Wound Care Institute and Hyperbaric Medicine, Baptist Medical Center, Jacksonville, FL

TBOZZ001@bmcjax.com

Billing Question

I am a physician running a free standing hyperbaric oxygen therapy center and we are unable to get payment from Medicare for the covered services i.e. wound healing, osteomyelitis, and failed grafts. I just found the new code c1300 on your message board. Is this the correct code? I’m told that the technical component is billed through Medicare part A, which can only be billed as a hospital. Is this true? Anybody have any suggestions?

Thanks.

ASPIEGE1@TAMPABAY.RR.COM

C1300 is the new HCPCS number.

Status Indicator is #S. # is “New technology APCs (range is 0970-0984)”

S is “Significant procedure, not discounted when multiple” This information can be downloaded directly from the HCFA web site at:

http://www.hcfa.gov/medicare/itemelig.xls

HBOT and CP in Fort Worth, TX

In August we started a trial treating children with cerebral palsy with HBOT. We started with motor skills testing on twenty children and are treating them five at a time. We continue to follow the patients waiting to get in the chamber so the kids waiting for therapy act as a “control” although it is not a blinded study. The therapy is 60 treatments of HBOT at 1.5 ATA for 60 minutes. It takes more than 12 calendar weeks to finish a group through 60 treatments so we have just finished our second group. We had two drop out prior to HBOT for personal reasons. So far we have put PE tubes in everyone but with the third group we are going to try to do it without tubes. We talked to Dr. Neubauer in Florida and he does not put tubes in any of his patients. This would significantly reduce the cost to us for the therapy. Since this is a study, our patients are paying nothing out of pocket. Things we have learned so far if and when we do a larger study - placebo controlled blinded. I would make the next group mainly kids less than 8 or 10 years old with spastic CP. The spasticity seems to be the thing that HBOT benefits the most. We need to have a better diagnosis of CP. Some parents say their kids have CP when it is really some congenital / chromosomal abnormality. There needs to be a better measure of spasticity. This may not be invented yet. Muscle spasticity seems to get better. However with each growth spurt the spasticity gets worse again so HBOT may need to be repeated.

Alvin Mathe, DO

Asst. Professor, Dept. of Internal Medicine

University of North Texas Health Science Center at Fort Worth.

amathe@hsc.unt.edu

My daughter is undergoing HBO for petit-mal seizures

My daughter Rachael is 13 years old and we just found out that she has petit mal seizures along with brain damage, either from anoxia at birth or undiagnosed seizures. My D.O. prescribed 100 hours of HBOT. So far we haven’t got the insurance company to pay. How does that work? So far my daughter has shown improvement and we want to continue with treatments.

Please let me know any inside secrets that will get the insurance to cover this. Thank you for your time.

Jamie Nelson

JNelsonPeace@aol.com

Dear Ms. Nelson:

This is indeed a timely question because there is now a growing grassroots movement starting to approach the problem of reimbursement for HBOT in treating neurological disorders on a State-by-State basis. The first State to pass such a law is Texas (HB 1676) which went into effect on September 1, 2001. The need for such legislation is obvious; insurance companies will not pay for any therapy they don’t have to pay for, and no one is making them pay for treating neurological conditions with HBOT, so they don’t.

In the case of the Texas bill, the wording is nonspecific, “A health benefit plan may not limit or exclude coverage for cognitive therapy, neuropsychological testing or treatment, or community reintegration activities necessary as a result of a traumatic brain injury.” As you can read there is no mention of HBOT, but Texas law has something called legislative intent, and in the case of HB 1676, almost all the testimony on behalf of the legislation was from proponents of HBOT.

I have just started working on a Bill I would like to see introduced in New Mexico, but my State does not have “legislative intent,” so we must make the wording very specific, for example, the below is how I propose the wording of the New Mexico Bill would start off:

“COVERAGE FOR NEUROPSYCHOLOGICAL TESTING AND TREATMENT

A. Each individual and group health insurance policy, health care plan and certificate of health insurance delivered or issued for delivery in this state shall provide coverage for Hyperbaric Oxygen Therapy, neuropsychological testing or treatment, or community reintegration activities necessary as a result of either a traumatic brain injury or any other disorder affecting the central nervous system, including but not limited to stroke, cerebral edema, cerebral palsy, multiple sclerosis, anoxic encephalopathies, any other autoimmune or other disease affecting the central nervous system.”

I can e-mail the proposed New Mexico Bill on request (info@simplyhyperbarics.com) to any interested reader, but it should be obvious that we have to be very specific with the wording.

Most brain-injured children are Medicaid recipients, and according to Title XIX of the Social Security Act, as described in 42 U.S.C. §1396 (a)(43), Medicaid-participating states must provide to eligible minors under the age of 21 certain mandatory medical services including Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT). Also, in paragraph (5) of the EPSDT statute found in 1396d(r), is a requirement that States provide “such other necessary health care, ...treatment and other measures...to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.”

The Medicaid law for children (the EPSDT), is found at 42 USC § 1396d(r), and can be found on the internet at:

http://caselaw.lp.findlaw.com/casecode/uscodes/42/chapters/7/subchapters/xix/sections/section%5F1396d.html

Paragraph 5 is the most relevant for Hyperbaric Oxygen Therapy. Ten years ago Paragraph 5 was added , it reads “(5) Such other necessary health care, diagnostic services, treatment, and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.”

It is no typographical error that “medically necessary” is not found in Paragraph 5. The authors knew that it can take as long as 10 or 15 years before a treatment, procedure, drug, or device could be categorized as “medically necessary.” Therefore the language of Paragraph 5 provides the opportunity for the EPSDT statute to create its own definition of medical necessity based on whether the service is necessary to correct or ameliorate a defect or condition. In the case of Hyperbaric Oxygen Therapy, the efficacy of the treatment can be verified by objective scientific analysis of SPECT-scan imaging before HBOT and after a certain number of treatments.

Incidentally, Medicaid was created by, Lyndon Baines Johnson specifically for brain-injured children. When it was created in 1967, President Johnson stated “The problem is to discover, as early as possible, the ills that handicap our children. There must be continuing follow-up and treatment so that handicaps do not go untreated.” (13 Congressional Record 2883. February 8, 1967). I would like to believe that State Medicaid offices are more interested in enabling brain-injured children than in perpetuating disability, but the only way to find out is to request coverage for HBOT on a State-by-State basis.

Kenneth Stoller, MD, FAAP

Medical Director of Simply Hyperbarics

Santa Fe, New Mexico

www.simplyhyperbarics.com

Sickle Cell Anemia

Do you have any information on HBOT and sickle cell anemia? Does it help?

Debbie Cone

djcone@intellisys.net

A review of the literature will show several papers published on HBOT & sickle cell conditions. We will be posting a collection of various papers on conditions treated with HBOT and sickle cell anemia will be one of them. We will also be running an article on HBOT & sickle cell anemia in the very near future.

HMT Staff