05/11/2022 David E. Samuel, DPM
Hyperbaric Oxygen is the "Nectar of the Gods": MA Podiatrist (Allen Jacobs. DPM)
Thanks Dr. Jacobs for those stats. This is so
classic in that therapies that could have some
benefits in very specific circumstances are
destroyed and become not payable for over
utilization purely based on the mighty dollar.
This will happen to graft codes soon enough,
putting thousands of dollars of quality products
on ulcers that are not properly off-loaded,
compressed, debrided, etc., and would never heal
until a met head is excised or vascular status
maximized, or compression therapy initiated, to
allow for healing.
Wonder why they want to limit applications now?
Keep using them 8 times on your patients who walk
in the door in their normal shoes, carrying their
knee scooter or holding their crutches/walker,
swearing they ‘hardly’ walk on it. Why is PRP or
amniotic injections considered experimental and
not covered by so many, if not all carriers?
Because for a few buck profit, PRP, etc. would be
abuse for so many simple things, that a few ccs of
dex or Kenalog would otherwise fix. Approving
these potential very beneficial things, opens a
Pandora’s box for the carriers, for what would
likely be over utilized, costing astronomical
amounts, and therefore will likely and
unfortunately not ever be an approved option for
us to use judiciously.
I have seen the wound center dive patients
30/45/60 dives and still have yet to see a
vascular surgeon to eval, stent or bypass to
maximize flow, then MAYBE HBO might have a
benefit. Now I understand it is quite hard to get
approval for dives. Or my favorite waste of
dollars and time is the MRI ordered to DIAGNOSE
OSTEO, (which still makes me scratch my head as to
when this was ever taught or known to be true or
why it is ordered so frequently to ‘Look for
osteo’, when it is not diagnostic).
I am not sure if it still is, but a diagnosis of
osteo also used to be a qualifier for HBO
treatments, so of course, get an MRI that will
light up purely based on marrow edema, secondary
to met head pressure under the ulcer, thus
‘proving’ osteo to allow for HBO reimbursement. Or
cover your butt when your x-ray report comes back
from the radiologist that says ‘no clinical
evidence of osteo. MRI suggested for further
evaluation’. They get paid again for an MRI.
You are stuck now treating a study, that you know,
or should know, proves nothing. Just a thought,
maybe go with the negative xray you reviewed,
under an ulcer, that you can see on debridement is
not into the deep structures/bone. Why not
offload, treat locally, check films in a few more
weeks, even some oral antibiotics.
If by chance, it gets deeper or new films now
shows your initial assessment is not right, and
now you finally see some periosteal changes, what
harm has occurred. You told your patient, MRIs are
not diagnostic. We’ll give you a little
antibiotics. We are going to treat this locally
and aggressively and it might be there, but the
only way to be sure is with a biopsy.
But in light of having an open wound, a biopsy
also has a risk to potentially introduce
infection, so why risk that and we will just treat
and be vigilant and look for changes later. We can
always biopsy and/or resect some bone and continue
treatment, if changes are seen. Would you
personally agree to radical debridement of your
metatarsal, toe, etc. based on an MRI? Good
documentation and a logical medically based game
plan is a solid defense for those thinking
defensive medicine, as I understand the world we
live in.
Also, perhaps have an educational discussion with
your radiologist, asking how is this DIAGNOSTIC
and perhaps in the future just read the findings
and if they are inclined to want to leave a
differential fine. But a ‘rule out osteo’ Rx is
going to come back osteo if the met head lights up
on an MRI, contrast or not, 9/10 x based on just
pressure.
I agree also with what Dr. Jacobs added. Use your
education. Use what you know is right and stand by
it, even educate your PCPs, Radiologist, ID docs,
medical residents, etc., leaving clear
explanations in your notes as to why treating a
study is not how to do it, and explaining the
game plan and logic behind it. It can save you and
your patients, time, money, and potentially
unnecessary treatments/surgery. If practice is
based on fear, and worrying about what others
think, (that may not be as versed in some areas as
you are), MRIs would be ordered for every headache
for fear of missing a brain tumor.
David E. Samuel, DPM, Springfield, PA
