Electrical stimulation being reimbursed again
Therapy group wins court ruling
Score a big point for physical therapists in the ongoing battle over Medicare coverage for electrical stimulation. In November, a U.S. District Court Judge in Massachusetts issued a preliminary injunction against the Health Care Financing Administration (HCFA) in response to a lawsuit filed by the American Physical Therapy Association (APTA) and six patients.
Under the injunction, HCFA must stop enforcing its July decision to halt Medicare reimbursement for electrical stimulation therapy in the treatment of chronic wounds. The injunction is seen as a major victory for APTA.
Judge George O’Toole’s ruling essentially restored the coverage policy for electrical stimulation to the way it was before HCFA’s discontinuation of coverage. Now Medicare carriers and intermediaries are once again authorized to cover and reimburse electrical stimulation therapy in cases for which such therapy is deemed reasonable and necessary.
The preliminary injunction will remain in effect until HCFA reconsiders its coverage guidelines and reports back to the judge. At that time he will rule whether or not to issue a permanent injunction or to review HCFA’s revised coverage guidelines.
"On behalf of the patients requiring wound care and the physical therapists who treat them, we are relieved that Medicare beneficiaries will be able to again receive Medicare coverage for electrical stimulation treatments where appropriate," says Jan Richardson, PT, PhD, OCS, president of APTA. "Without this type of physical therapy, many patients are at risk for severe infection, possible tissue and limb loss, and even loss of life."
In his ruling, O’Toole stated that "in this case, there needs to be, at the least, a better explanation by HCFA of its coverage determination and, perhaps, a revision of that determination."
HCFA had said it issued its national non-coverage decision primarily on information provided by ECRI, a health technology assessment consulting firm. After analyzing several published studies on the effectiveness of electrical stimulation in chronic wound treatment, ECRI found minor methodological flaws, but ultimately concluded that the studies supported the safety and efficacy of electrical stimulation.
O’Toole cautioned HCFA not to erect an "impassable barrier" when analyzing existing studies. He said clinical patients with intractable wounds are not experimental animals, and it is perhaps an impossible expectation to demand that studies involving real patients have all the controlled perfection of laboratory studies. "Such an expectation seems less defensible here because the analysts of the data have said, in effect, that the ES studies are about as good as one gets in this area," his ruling stated.
Other data also support the efficacy of electrical stimulation for wound care, the judge noted. A study by the federal Agency for Health Care Policy and Research (AHCPR) gave electrical stimulation its second-highest rating after an extensive review of the literature.
AHCPR’s clinical practice guidelines for pressure ulcers, issued in 1995, recommended electrical stimulation as an effective therapy for stage III and IV ulcers and for recalcitrant stage II ulcers.
HCFA has not commented on the ruling, saying its policy is to withhold comments on pending court cases.