Mountain State Medical Policy Bulletin |
Section: | Miscellaneous |
Number: | Z-3 |
Topic: | Hyperbaric Oxygen (HBO) Therapy |
Effective Date: | October 17, 2005 |
Issued Date: | October 17, 2005 |
Date Last Reviewed: | 11/2005 |
Indications and Limitations of Coverage
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/investigational. Scientific evidence does not demonstrate the effectiveness of this service. Claims reporting topical HBO therapy or devices (A4575) used to administer this therapy will be denied. HBO therapy is limited to the diagnoses/conditions listed below:
HBO therapy has been expanded to include coverage for the treatment of diabetic wounds of the lower extremities in patients who meet the following criteria:
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. 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. Standard wound care in patients with diabetic wounds includes:
When any of the above diagnosis codes are reported, the patient's records must document the exact diagnosis/condition annotated on this list. Use of HBO therapy for other conditions should be denied as not medically necessary and therefore, not eligible for payment. A participating, preferred, or network provider cannot bill the member in this instance. If no diagnosis is reported, the claim will be developed and processed based on the information obtained. Description HBO therapy (99183) is a treatment in which the entire body is exposed to oxygen under increased atmospheric pressure. |
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99183 | A4575 |
All services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient’s condition. Topical HBO therapy and application of the device are eligible services when determined medically necessary based on the patient’s condition. |
PRN References 08/1995, Hyperbaric oxygen (HBO) therapy |
[Version 001 of Z-3] |