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:

• Actinomycosis refractory to antibiotics and surgical treatment (039.0-039.9)
• Anemia with exceptional blood loss (280.0, 285.1, 785.59)
• Carbon monoxide intoxication (acute) (986)
• Chronic refractory osteomyelitis (730.10-730.19)
• Crush injuries and suturing of severed limbs, when loss of function, limb or life is threatened (927.00-927.09, 927.10-927.11, 927.20-927.21, 927.3, 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)
• Cyanide poisoning (987.7, 989.0)
• Decompression illness (993.3)
• Gas embolism (958.0, 999.1)
• Gas gangrene (040.0)
• Necrotizing fasciitis (728.86)
• Osteoradionecrosis as an adjunct to conventional treatment (526.89)
• Peripheral arterial insufficiency (acute) (444.21-444.22)
• Preparation and preservation of compromised skin grafts (V42.3)

  NOTE:

  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)
• Traumatic peripheral ischemia (acute), when loss of function, limb, or life is threatened. (The same codes listed above for "Crush Injuries" are applicable.)
• Prophylactic pre- and post-treatment for member undergoing dental surgery of a radiated jaw (V07.8, V07.9)

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:

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. 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:

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.

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.

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.

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
12/1995, Hyperbaric oxygen (HBO) therapy
08/1996, Hyperbaric oxygen (HBO) therapy
08/2000, Hyperbaric oxygen (HBO) therapy
10/2002, Hyperbaric oxygen (HBO) therapy
12/2005, Hyperbaric oxygen (HBO) therapy