MaineCare Prior Authorization
Provider Instructions for requesting Hyperbaric Oxygen Treatment
Chapter II, Section 90.05-1,I (http://www.maine.gov/sos/cec/rules/10/ch101.htm) FAX OR MAIL REQUEST, PLEASE DO NOT DO BOTH. Please allow up to 30 calendar days from the date the request is received in the Prior Authorization Unit to review and make a decision. To request a prior authorization for this service, a letter of medical necessity needs to be completed and signed by the provider who is planning on performing the service. The body of the letter needs to have the following information addressed: Date of request Member Full Name (ex: John Doe) MaineCare ID number (ex: 87198451A – 8 numbers and one letter usually ending with an A or T) Date of Birth Diagnosis MaineCare Billing Provider ID number Scheduled Appointment Date Reason for Visit (ex: outpatient rheumatology, inpatient admission) Proposed treatment plan and procedure code(s) Name of referring physician’s office and specialty Referring physician’s telephone number, fax number and printed name Please attach information listed below with your request: Referring physician’s notes and evaluation PA Criteria To Approve Request: Documentation (medical records, wound clinic records) describing the covered conditions, which include: a. Acute carbon monoxide intoxication b. Decompression illness c. Gas embolism d. Gas gangrene e. Acute traumatic peripheral ischemia therapy used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened f. Crush injuries and suturing of severed limbs as an adjunctive treatment when loss of function, limb, or life is threatened. g. Progressive necrotizing infections (necrotizing fasciitis); h. Acute peripheral arterial insufficiency; i. Preparation and preservation of compromised skin grafts (not for primary management of wounds);
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MaineCare Prior Authorization j. k. l. m. n. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management; Osteoradionecrosis as an adjunct to conventional treatment; Soft tissue radionecrosis as an adjunct to conventional treatment; Cyanide poisoning; Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment; o. Diabetic wounds of the lower extremities in patients who meet all of the following three (3) criteria: Patient has type I or II diabetes and has a lower extremity wound due to diabetes; Patient has a wound classified as Wagner grade III or higher (Wagner grades of wounds can be found on the internet at http://www.ncbi.nlm.nih.gov/bv.fcgi?rid=surg.table.4595 Patient has failed an adequate course of standard wound therapy. Note: MaineCare does not cover topical application of oxygen. It does not meet the definition of HBO therapy. Its efficacy has not been established. Diabetic wounds only
□ Covered as an addition to standard wound care only after there are no measurable signs of healing
for at least thirty (30)–days of treatment with standard wound therapy □ Wounds must be evaluated at least every thirty (30) days during administration of HBO therapy. □ Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any thirty (30)-day period of treatment. □ Standard wound care in patients with diabetic wounds includes: Assessment of a patient’s vascular status and correction of any vascular problems in the affected limb if possible Optimization of nutritional status Optimization of glucose control Debridement by any means to remove devitalized tissue Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings Appropriate off-loading, and Necessary treatment to resolve any infection that might be present.
Request will be Deferred (need additional information) when:
□ No physician signature. □ Inadequate medical records.
Request will be Denied when:
□ Requested/Deferred information was not received within 30 days. □ Request did not establish medical necessity met per policy. □ The request is for a non-covered condition, which include:
Cutaneous, decubitus and stasis ulcers;
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MaineCare Prior Authorization Chronic peripheral vascular insufficiency; Anaerobic septicemia and infection other than clostridial; Skin burns (thermal); Senility; Myocardial infarction; Cardiogenic shock; Sickle cell anemia; Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency; Acute or chronic cerebral vascular insufficiency; Hepatic necrosis; Aerobic septicemia; Nonvascular causes of chronic brain syndrome (Pick's disease, Alzheimer's disease, and Korsakoff's disease); Tetanus; Systemic aerobic infection; Organ transplantation; Organ storage; Pulmonary emphysema; Exceptional blood loss or anemia; Multiple sclerosis; Arthritic diseases; or Acute cerebral edema; or All other indications not listed as covered conditions above.
Wagner Classification & Associated Pathogens http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=surg.table.4595
Grade Zero One
Definition No ulcer Superficial skin ulcer
Typical pathogens “Normal” skin flora Predominantly gram-positives, (Steptococcus, the Staphylococcus,
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MaineCare Prior Authorization Enterococcus spps.) lesser numbers of aerobic gram-negatives and anaerobes. Bacterial population is more homogenous.
Two
Deep ulcer extending through dermis. Tendon, ligaments, joint capsule or bone may be exposed. Deep ulcer with abscess, osteomyelitis or joint sepsis Localized gangrene – forefoot or heel Gangrene of the foot
Three Four Five
Polymicrobial (gram-positive, gramnegative and anaerobic) infections with increased numer of the latter two species. Bacterial population is more heterogeneous.
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