Hyperbaric oxygen (HBO) therapy is a treatment in which the body is exposed to oxygen under increased atmospheric pressure. 

Payment is limited to therapy administered in a chamber to the entire body, which because of the equipment involved, is typically (but not always) performed either inpatient hospital or outpatient hospital. Topical application of oxygen does not meet the definition of HBO therapy and is still considered experimental. Claims reporting topical HBO therapy or devices (A4575) used to administer this therapy should be denied.

In addition, HBO therapy is limited to the conditions/diagnosis codes below: 

• Actinomycosis refractory to antibiotics and surgical treatment (039.0-039.9)
• Carbon monoxide intoxication (acute)(986)
• Chronic refractory osteomyelitis (730.10-730.19)
• Cyanide poisoning (987.7, 989.0)
• Crush injuries and suturing of severed limbs, when loss of function, limb or life is threatened (927.00-927.03, 927.09-927.11, 927.20-927.21, 927.8-927.9, 928.00-928.01, 928.10-928.11, 928.20-928.21, 928.3, 928.8-928.9, 929.0, 929.9, 996.90-996.99)
• Decompression illness (993.3)
• Gas embolism (958.0, 999.1)
• Gas gangrene (040.0)
• Progressive necrotizing infections (necrotizing fasciitis)(728.86)
• Osteoradionecrosis as an adjunct to conventional treatment (526.89, 909.2)
• Peripheral arterial insufficiency (acute)(444.21-444.22, 444.81, 902.53, 903.01, 903.1, 904.0, 904.41)
• Preparation and preservation of compromised skin grafts (996.52). [This is not intended to cover preparation for an initial skin graft. Coverage is limited to attempts to preserve an existing skin graft which is compromised (i.e., showing signs of failure or rejection, dying tissue, etc.)].
• Soft tissue radionecrosis as an adjunct to conventional treatment (990, 909.2)
• Traumatic peripheral ischemia (acute), when loss of function, limb, or life is threatened (The same codes listed above for “Crush Injuries” are applicable.)

HBO therapy use has been expanded to include coverage for the treatment of diabetic wounds of the lower extremities in patients who meet the following criteria:

1. Patient has Type I or Type II diabetes and has a lower extremity wound that is due to diabetes (250.70-250.73, 250.80-250.83, 707.10-707.19);
2. Patient has a wound classified as Wagner grade III or higher; and,
3. Patient has failed an adequate course of standard wound therapy.

The use of HBO therapy will be covered as an adjunctive therapy only after there are not measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care.

It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation.

Standard wound care in patients with diabetic wounds includes:

1. Assessment of a patient's vascular status and correction of any vascular problems in the affected limb if possible;
2. Optimization of nutritional status and glucose control;
3. Debridement by any means to remove devitalized tissue;
4. Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings;
5. Appropriate off-loading; and
6. The necessary treatment to resolve any infection that might be present.

Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy.  Continued treatment with HBO treatment is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation.

Use of HBO therapy for any other conditions should be denied as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost.  The member must agree in writing to assume financial responsibility, in advance of receiving the service.  The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

HBO therapy should not be a replacement for other standard successful therapeutic measures. 

A course of HBO treatment may range from less than one week to several months duration, averaging from two to four weeks. Claims reporting the use of HBO therapy for more than two months duration should be referred for medical necessity determination.

When a covered diagnosis code is reported, the patient’s records must document that exact diagnosis/condition annotated above. The patient’s medical record must be available upon request.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Report 99183 for HBO treatment of diabetic wounds of the lower extremities.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

CMS Online Manual Pub. 100-03, Chapter 1, Section 20.29

See “Indications and Limitations of Coverage” section.