Facilitating Insurance Coverage For Venous Ablation Procedures

Posted on Jun 26, 2017

This is a follow up to my previous blog post regarding venous ablation procedures. I recently had an eye-opening conversation with a vascular surgeon, Jane Lingelbach, MD, with whom I work closely at Healogics Wound Care Center. She recently expressed why there is a delay of treatment from the time of a requested consult to the time of a venous ablation procedure performed due to an ulceration in the presence of venous disease if indicated. Dr. Lingelbach says there is often a a lag time between her recommendation and treatment, calling it “all insurance driven.” The mainstay requirement for most insurance is that the patient must have attempted three months of conventional compression therapy prior to a venous procedure. This could have started prior to the initial patient presentation. She said in extreme cases, insurance companies may ask for proof of purchase if patients were using compression stockings. She recommends her patients save their receipts. Also, according to Dr. Lingelbach, it is important to document when the patient first started any compression therapy. For example, if patients state that their primary care physician recommended compression stockings and they have been wearing them for one month, one needs to document this. Therefore, we have to try two more months of conventional treatment prior to the patient having a venous ablation procedure. According to www.veindirectory.org , the HMO and PPO insurance companies use varying criteria in order to determine if they may consider vein treatment to be “medically necessary.” These criteria may include one or more of the following factors. • Lifestyle disruption. The daily activities of the patient must be disrupted significantly. • Pain. The patient must be experiencing pain as a result of the vein disorder. • Failure of conservative measures. Other methods of treatment, such as compression hose, have failed to provide adequate relief. • Vein size. Bulging veins larger than 4 mm are often considered medically significant. • Complications. Complications such as phlebitis, bleeding veins, leg swelling and leg ulceration make it more likely an insurance company will consider treatment medically necessary. According to Medicare, medically necessary signs and symptoms include pain, swelling and ulceration. In these cases, after documentation of venous insufficiency by ultrasound, Medicare will usually deem endovenous ablation and ambulatory phlebectomy to be medically necessary. As podiatrists, we do not perform these venous ablation procedures but we often refer venous ulceration patients to vein clinics and/or vascular surgeons. Therefore, it is important to be aware of the insurance guidelines so we can assist these patients if we feel they may benefit from a venous procedure. It is important to initiate compression therapy as soon as possible in patients with venous ulcers unless it is contraindicated (for...

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When Should You Refer Patients For Venous Ablation?

Posted on Jun 20, 2017

I often have patients at the wound center who get referrals to me for care after a venous ablation procedure. I researched the procedure to explore what is involved and when we should be referring patients to a vein clinic or a vascular surgeon. In order to understand what venous ablation entails, we need to review the nature of venous insufficiency. Chronic venous insufficiency is the cause of many chronic ulcers in the lower extremity. The venous system is made up of both the superficial and deep vein system. These systems are connected by perforating veins as well as the great saphenous vein and lesser saphenous vein. Failure of the one-way valves separating both systems can lead to high pressures in the superficial systems, causing aching, which can lead to skin changes and ulcerations. As the valves are damaged, blood leaks and flows backward, causing the increased pressure in the vessels. Ulcerations occur in areas where blood collects and pools. As swelling occurs, this can interfere with the movement of oxygen and nutrients into the tissue. The most common cause of ulceration in the lower extremity due to venous disease is the great saphenous vein area (medial ankle area). This problem is the cause of 60 to 80 percent of chronic leg ulcerations.1,2 The incidence of these ulcerations increases with age. Risk factors include: family history, sedentary lifestyle and jobs that require people to stand for an extended period of time. The easiest way of treating venous insufficiency or reflux is compression therapy. If this does not help, venous ablation may be a good option. Venous ablation is a non-surgical technique that has replaced vein stripping in most cases.3 Using only a local anesthetic, vascular surgeons can eliminate the abnormal refluxing vein by sealing it closed. The surgeon makes a small incision at the knee and places a small tube into the saphenous vein. Then he or she passes a laser or radiofrequency fiber through the tube into the vein. Once this fiber is in place, the fiber activates and delivers very localized heat to the vein wall. In response, the vein closes down and becomes permanently blocked. If you have been seeing a patient for a venous wound and have been using conventional compression therapy without seeing wound healing in a reasonable timeframe or significant progress in four weeks, I suggest you consider a vascular consult or refer the patient to a vein clinic. References 1. Whiddon LL. The treatment of venous ulcers of the lower extremities. Proc (Bayl Univ Med Cent).2007;20(4):363-366. 2. New York-Presbyterian Hospital. Venous insufficiency and venous ulcers.http://nyp.org/services/venous-insufficiency-ulcers.html 3. Dotter Interventional Institute, Oregon Health and Science University. Venous ablation.http://www.ohsu.edu/dotter/venous_ablation.htm . Updated March 15, 2011. Accessed May 19,...

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Managing Postthrombotic Syndrome Following DVT

Posted on Jun 10, 2017

At my wound center, I recently had several patients whom I was treating for leg ulcers. At first glance, the ulcers seemed like classic venous wounds. After reviewing the patient histories, the one thing that they all had in common was a history of deep vein thrombosis (DVT). If one refers to venous stasis syndrome occurring after a DVT, an appropriate term is “postthrombotic syndrome.” Prior to this research, I was familiar with postthrombotic syndrome but was unsure of the best way to treat these patients. Postthrombotic syndrome or postphlebitic syndrome is a medical condition that can develop in patients who experience a DVT in the leg. When the body tries to heal from these clots, the valves in the veins are often damaged. The obstruction of the veins and the destruction of valves lead to impaired blood flow. It is a result of venous hypertension, which occurs as a consequence of recanalization of major venous thrombi. This leads to patent but scarred and incompetent valves or, less frequently, persistent outflow obstruction produced by large proximal vein thrombi. Recanalization and valve destruction result in a malfunction of the muscular pump mechanism, which leads to increased pressure in the deep veins of the calf. This high pressure results in progressive incompetence of the valves of the perforating veins of the calf. When this occurs, blood flow directs from the deep vein into the superficial system during muscle contraction, leading to edema and impaired viability of subcutaneous tissues and, in its most severe form, ulceration of venous origin. Symptoms include chronic leg pain, swelling, redness and sometimes ulcers. Post-thrombotic syndrome affects an estimated 330,000 people in the United States with 23 to 60 percent occurring two years following DVT of the leg.1,2 Approximately 60 percent of patients will recover from a leg DVT without any residual symptoms. Forty percent will have some degree of postthrombotic syndrome, 4 percent will have severe symptoms and 10 percent develop venous ulcerations. Symptoms usually occur within the first six months but can occur up two years after the clot. What are the risk factors of postthrombotic syndrome?3 History of proximal deep vein thrombosis (above the knee) Having more than one blood clot in the same leg more than once Still having blood clot symptoms one month after being diagnosed with the blood clot Obesity Difficulty with international normalized ratio levels during the first three months after starting anticoagulants Symptoms include:3 Chronic aching Swelling Fatigue Heaviness Edema Hyperpigmentation Subcutaneous fibrosis in the affected limb Venous claudication Venous leg ulcers Preventing And Treating Postthrombotic Syndrome Prevention is the key to preventing complications after a DVT. If a person has leg swelling after an acute DVT, he or...

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Revisiting The Role Of Extracellular Matrices In Wounds

Posted on Jun 7, 2017

The extracellular matrix is the largest component of normal skin, providing skin with its properties of compressibility, elasticity and tensile strength.1 It is comprised of connective tissues and fibers that provide support but are not part of a cell The extracellular matrix’s cellular scaffolding signals the direct cells to divide, differentiate and build themselves into a specific form.1 In healthy skin, the extracellular matrix helps support cells and comprises key components of the basement membrane, which anchors and helps replenish epidermal cells. Extracellular matrices have a variety of functions including: • cell communication within tissue and tissue formation • structural and biochemical support to the surrounding cells • cell adhesion, cell-to-cell communication and differentiation • support, segregating tissues from one another, and regulating intercellular communication • sequestering of a range of cellular growth factors and acts as a local store • regulation of a cell’s dynamic behavior • being an essential component of processes like cell growth, wound healing and fibrosis • holding cells together to form a tissue The components of extracellular matrices include proteins, such as collagens, laminins, fibronectin and elastins. Collagen is the most abundant fibrous protein within the interstitial extracellular matrix and constitutes up to 30 percent of the total protein mass.2 Extracellular matrices also include glycoproteins, glycosaminoglycans and proteoglycans. The extracellular matrix is integral to each phase of wound healing, interacting with cells and growth factors in a dynamic process that eventually results in wound closure. When the extracellular matrix is dysfunctional, wound healing slows or stalls. Chronic wounds contain increased levels of inflammatory cells, giving rise to elevated levels of proteases that appear to degrade the extracellular matrix components, growth factors and receptors that are essential for healing.1 Understanding of the importance of re-establishing a functional extracellular matrix in chronic wounds has led to technical advances and the development of products that reduce excessive protease levels or contribute functional extracellular matrix proteins, thereby facilitating the healing process. Such products include Oasis Wound Matrix (Smith and Nephew), an intact matrix that is derived naturally from porcine small intestinal submucosa. When one applies extracellular matrix to a wound, it does not trigger an immune response. Instead, when it begins to break down into surrounding tissue, it causes the cells in that tissue to start repairing the damage. Cells divide and rebuild, creating new, normal tissue, not scar tissue. References 1. Schultz GS, Ladwig G, Wysocki A. Extracellular matrix: review of its roles in acute and chronic wounds. World Wide Wounds. Available at   http://www.worldwidewounds.com/2005/august/Schultz/Extrace-Matric-Acute-Chronic-Wounds.html . Published August 2005. Accessed Jan. 6, 2015. 2. Boundless. An overview of the extracellular matrix found in animal cells. Boundless Anatomy and Physiology. Available at https://www.boundless.com/physiology/textbooks/boundless-anatomy-and-physiology-textbook/cellular-structure-and-function-3/external-cellular-components-47/an-overview-of-the-extracellular-matrix-found-in-animal-cells-350-11461/ . Published July 3, 2014....

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Remembering Nutritional Analysis In The Wound Care Patient

Posted on Apr 23, 2017

While attending a conference a several weeks ago, I ran into a colleague whose passion and expertise, like mine, is wound care. Our conversation centered upon the topic of nutrition and how often as doctors, we omit the patient’s dietary habits in our treatment strategies. We are so focused on healing the wound that we may overlook the basics that would assist the healing process. Typically as physicians, when we treat an ulcer, we are focused on the wound bed itself. In these situations, the patient often has several comorbidities typically including uncontrolled diabetes, which may translate into a poor diet and eating habits. While patients should be monitoring their blood glucose level daily, we need to monitor their nutritional status. I currently am a physician panelist at a Healogics wound care center in the Washington, DC area. In addition to the standard lab tests, while not mandatory, I have started a new process of ordering baseline nutritional markers to establish a baseline with my patients. Standard lab tests  ● Basic blood work ● Complete blood cell (CBC) with differential ● CHEM-7 panel ● HbA1c Additional nutritional markers ● Albumin (normal 3.4-5.4 g/dL) ● Prealbumin (normal 15-36 mg/dL) ● Any additional labs depending on the patient’s medical history A serum albumin test measures the amount of albumin in the clear liquid portion of the blood. This test can help determine if a patient has liver disease or kidney disease, or if the body is not absorbing enough protein. The body uses prealbumin as a building block to make other proteins. You might order this test if the patient appears to be malnourished or if you want to follow the patient’s nutritional progress. One should monitor the results of these tests periodically and discuss them with patients to educate them on how their nutritional diet impacts their health and the wound healing process. When there are abnormal nutritional results, the patient should get a referral to an endocrinologist or nutritionist for further evaluation. In addition to focusing on the wound, we need to remember to evaluate what is feeding the wound for total patient care. Looking at the whole picture and leveraging a more expanded team approach to include nutrition, in my opinion, is the missing link in wound treatment. Suggested Reading 1. Available at http://www.nlm.nih.gov/medlineplus/ency/article/003480.htm . Published Feb. 13, 2013. Accessed April 22, 2014. 2. Available at http://blog.beckydorner.com/2013/12/use-of-serum-albumin-and-prealbumin-… . Accessed April 22, 2014. 3. Available at http://www.webmd.com/a-to-z-guides/total-serum-protein . Published Nov. 4, 2011. Accessed April 22, 2014. Original Posted on Podiatry...

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A Closer Look At Amniotic Membrane Allografts For Wounds

Posted on Nov 12, 2014

Recently my organization, the American Association for Women Podiatrists, hosted a scientific conference in San Diego. One of the speakers was Marie Williams, DPM, who discussed the advances in regenerative medicine in wound care. Listening to her presentation left me with more questions. Here is what I found. The Centers for Disease Control and Prevention (CDC) has projected that by 2050, as many as one out of three U.S. adults could have diabetes.1 As many as 25 percent of patients with diabetes will develop an ulceration in their lifetime.1 The goal is to heal these wounds in the fastest manner possible in order to prevent infection, ulceration and amputation. If an ulcer does not respond appropriately to standard care at four weeks, then it requires re-evaluation of the current treatment plan and one should consider an advanced modality.2 Amniotic membrane allograft is a more recent advanced modality in wound care. Since the early 20th century, human amniotic membrane allografts have been in widespread use in a variety of applications including burn care, dentistry, ophthalmic, ear, nose and throat, and spine surgery. Human amniotic membrane products have become a widely accepted form of treatment in ophthalmic surgery, including corneal ulceration, covering of defects in large conjunctival lesions and acute chemical burns of the eye. Recently, physicians have effectively applied amniotic membrane products to help facilitate healing in chronic cutaneous wounds, including diabetic, venous, arterial and decubitus ulcers.3-7 The amniotic membrane derives from the inner layer of the placenta and is composed of conjoined amnion and chorion membranes. The amnion is in contact with the amniotic fluid/fetus and the chorion is in contact with the maternal side of the placenta. Both layers are non-immunogenic. Human amniotic membrane forms the lining of the fetal environment during gestation, separating the developing fetus from the mother in utero. The material used for surgical wound allografts is isolated from the membranous sac surrounding the infant to the point where it adjoins the placenta at the chorionic plate. The amniotic membrane is composed principally of structural collagen, extracellular matrix, biologically active cells and a large number of important regenerative molecules. Collagen types IV, V and VII make up the extracellular matrix, and are substrates that are important for the integrity of the membrane and ingrowth of cells. The membrane also includes proteins such as fibronectin, proteoglycans, glycosaminoglycans and laminins, epidermal growth factor (EGF), transforming growth factor (TGF), fibroblast growth factor and platelet-derived growth factors. Amniotic membrane has both matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs). Current Insights On The Benefits Of Amniotic Membrane There are a variety of benefits with the use of amniotic membrane products for wound healing.4,6 • The extracellular matrix scaffold...

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