President’s Blog

We are a wound care community and each play a role in the health of our treated patients. I attended the 5/19/2016 meeting of the Oregon Health Evidence Review Commission (HERC) Value-based Benefits Subcommittee to give medical expert testimony for 3 wound care related topics. The commission gives guidance to the Oregon Health Authority.
1) Lymphedema Therapy: Treatment strategies offered by physical therapists were being reviewed. Many were considered inappropriate or without substantial evidence of benefit. Pneumatic compression devices were being evaluated as to whether they offered benefit in a wide array of treatment modalities including lymphedema. No evidence of benefit for use in lymphedema was included in the literature review by the commission. I presented clinical trial data of how pneumatic compression therapy reduced costs, decreased infections, led to decreased clinical visits when used in lymphedema patients. Lymphedema will remain as a recommended condition for use of pneumatic compression devices. They offered to review consideration for adding lipedema as a treatment indication when trial data becomes available.
2) MIST/low frequency ultrasound: This treatment modality had been previously reviewed and the manufacturer had asked for a reconsideration of decision based on newer trial data. Prior meta-analysis review was inconclusive in regards to benefit of low frequency ultrasound. The manufacturer did highlight that some of the meta-analysis reviews included data from older trials and in some instances technologies that preceded the existence of low frequency ultrasound. I presented randomized trial data that had been published after the meta-analysis reviews (Gibbons, et al. A prospective, randomized, controlled trial comparing the effects of noncontact, low-frequency ultrasound to standard care in healing venous leg ulcers. Ostomy and Wound Management 2015 and Olyaie et al. High-frequency and noncontact low frequency ultrasound therapy for venous leg ulcer treatment: A randomized, controlled study. Ostomy and Wound Management 2013). The commission felt the additional data was not sufficient to alter their guidance of considering this treatment modality as experimental.
3) Hyperbaric oxygen therapy: The Oregon Health Plan had requested a change to the diagnosis code used for osteoradionecrosis of the jaw and to mandate review for progress of all hyperbaric treatment indications at 30 days. I informed the commission that CMS had already given guidance on the appropriate ICD-10 code for osteoradionecrosis of the jaw which is M27.8 and they agreed. I also pointed out that 30 day evaluation is really only most appropriate for diabetic foot ulcerations and they agreed. I also noted that other soft tissue related radiation injuries were not specifically listed as covered indications. I proposed that the following be approved ICD-10 indications for treatment given this had been the intention of CMS under ICD-9 guidance clarifications and recent Noridian LCD. In August these will likely be added to the approved indication category for hyperbaric indications related to radiation injury:

For osteoradionecrosis of jaw
526.89 Other specified diseases of the jaws
M27.8 Other specified diseases of jaws

For radiation cystitis
595.82 Irradiation cystitis
N30.40 Irradiation cystitis without hematuria
595.82 Irradiation cystitis
N30.41 Irradiation cystitis with hematuria

Radiation proctitis is not specified on LCD, but the following is the code
569.49 Radiation proctitis

For the other radiation soft tissue injury diagnoses using:
909.2 Late effect of radiation
L59.9 Disorder of the skin and subcutaneous tissue related to radiation, unspecified

On June 2, 2016 from 2-5 PM, skin substitutes will be again discussed. This decision had already been slated to be finalized, but I advocated on behalf of the wound care community to extend the public comment period so further clinical input could be added as to the finalized list of approved/recommended skin substitutes for advanced wound healing. I plan on attending this meeting as well to advocate for our wound care community.

These examples above highlight the importance of this organization to bring together different components of the medical community to take care of the whole patient. Lymphedema therapy is a physical therapy treatment modality. MIST therapy is most often done by nursing. Skin substitutes and hyperbaric oxygen are utilized by advanced practitioners and physicians/podiatrists. We all continue to learn from and advocate for each other. I look forward to seeing you at the next CWCC symposium on 7/30/2016.

Alejandro Perez, MD, RPVI, FSVM
President, CWCC Board of Directors

One Comment

  1. Barbara
    Posted 12/28/2016 at 9:02 am | Permalink

    Thanks for doing this Alex, we overlook these committees to our patients’ detriment too often.
    Barb Roark

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