Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Hyperbaric oxygen therapy (HBOT) is a systemic treatment in which the entire patient is placed inside a pressurized chamber and breathes 100% oxygen under a pressure greater than one atmosphere.  It is used to treat certain diseases and conditions that may improve when increased oxygen is present such as non-healing infected deep ulcerations, acute carbon monoxide poisoning, acute air or gas embolism, or radiation necrosis. 

2)    Emergency hyperbaric oxygen therapy is covered without pre-authorization for the first two units, when performed in the emergency department or as in-patient. Additional units require pre-authorization

3)    Continued treatment with HBOT for wound care is covered when there has been evidence of progressive healing during 30 days of treatment. A renewal of the pre-authorization is required every 30 days or more frequently depending on progress.

4)    For certain conditions, HBOT is considered experimental since HBOT has not been shown to be more effective than conventional treatment.  Examples:

a)    necrotizing arachnidism (severe tissue destruction due to venomous spider bites)

b)    acute or chronic cerebrovascular insufficiency (low blood supply to the brain)

c)     cerebrovascular accident (including thrombotic or embolic stroke)

5)    There are also conditions in which HBOT is dangerous and therefore, not a covered service such as:

a)    Untreated pneumothorax

b)    Concurrent administration of doxorubicin, cisplatin, or disulfiram

c)     Premature infants (birth prior to 37 weeks gestation)

6)    Contact Customer Service for coverage information.

The first two units for each code 99183 (supervision of hyperbaric oxygen) and G0277 (hyperbaric oxygen 30 minute session), when performed in the emergency room or inpatient hospital setting, do not require pre-authorization. This is to allow emergency hyperbaric oxygen treatment for certain conditions (such as acute carbon monoxide poisoning, decompression illness, acute air/gas embolism or cyanide poisoning).  Anything beyond the first two units requires preauthorization.  If retrospective review finds this is inappropriately being used for chronic conditions the payment may be retrospectively denied/adjusted.  

99183 and G0277 require pre-authorization in all other settings. 

In the outpatient setting, full body hyperbaric oxygen therapy (HBOT) is considered medically necessary for the following conditions:

1.     Non-healing infected deep ulcerations (reaching tendons or bone) of the lower extremity in diabetic adults unresponsive to at least 1 month of meticulous wound care (including aggressive debridement, maximal antibiotic therapy, tight glycemic control, and appropriate treatment of arterial insufficiency, including revascularization if necessary).
HBOT is not considered medically necessary for superficial lesions.

2.     Acute carbon monoxide poisoning.

3.     Decompression illness (“the bends”) – the standard treatment is recompression and decompression without increased oxygen concentration in the air.

4.     Acute air or gas embolism – the standard treatment is recompression and decompression without increased oxygen concentration in the air.

5.     Gas gangrene (Clostridia myositis and myonecrosis).

6.     Cyanide poisoning (with co-existing carbon monoxide poisoning).

7.     Acute traumatic peripheral ischemia (including crush injuries and suturing of severed limbs) when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy.

8.     Acute peripheral arterial insufficiency (e.g., compartment syndrome).

9.     Progressive necrotizing soft tissue infections, including mixed aerobic and anaerobic infections (necrotizing fasciitis, Meleney`s ulcer).

10. Chronic refractory osteomyelitis, unresponsive to conventional medical        and surgical management.

11. Compromised skin grafts and flaps.

12. Radiation necrosis (osteoradionecrosis, myoradionecrosis, and other soft tissue radiation necrosis) as an adjunct to conventional treatment.

13. Soft tissue radio necrosis as an adjunct to conventional wound care.

14. Exceptional blood loss anemia only when there is overwhelming blood loss and transfusion is impossible because there is no suitable blood available, or religion does not permit transfusions.

15. Pneumatosis cystoids intestinalis.

16. Prophylactic pre- and post-treatment for members undergoing dental surgery of a radiated jaw.

17. Acute cerebral edema.

18. Idiopathic sudden deafness, acoustic trauma or noise-induced hearing loss, when HBOT is initiated within 3 months after onset.

Billing: 

-        99183 is for professional services only, and is limited to one unit (session) per day.

-        G0277 is billed by the facility, in 30 minute increments, up to four hours per day.

Codes Used In This BI:

99183    Physician attendance/supv of hyperbaric oxygen therapy, per session

A4575    Hyperbaric O2 chamber disps

G0277   HBOT, full body chamber, per 30 minute interval

1.     HBOT is covered for wound care only when there have been no signs of healing following 30 days of standard wound care.

2.     Continued treatment with HBOT for wounds is not covered when there have been no signs of healing after 30 days.

3.     The use of HBOT is considered experimental and investigational for the following conditions because there is insufficient evidence in the medical literature establishing that HBOT is more effective than conventional therapies:

a.          Actinomycosis and other mycoses

b.          Superficial and/or non-infected diabetic ulcers

c.          Non-diabetic cutaneous, decubitus, pressure and venous stasis ulcers

d.          Chronic peripheral vascular insufficiency

e.          Acute renal arterial insufficiency

f.           Acute or chronic cerebrovascular insufficiency/accident (including

     Thrombotic or Embolic stroke)

g.          Anaerobic septicemia and infection other than clostridia

h.          Aerobic septicemia and systemic aerobic infection

i.            Pyoderma gangrenous

j.            Intra-abdominal abscess, pseudomembranous colitis (antibiotic-induced

     Colitis)

k.          Intracranial abscesses

l.            Skin burns (thermal)

m.        Acute thermal and chemical pulmonary damage, i.e., smoke inhalation

     (E.g. Carbon tetrachloride, hydrogen sulfide) with pulmonary insufficiency

n.          Tetanus

o.          Organ transplantation and storage

p.          Pulmonary emphysema

q.          Cognitive impairment (e.g., senility, senile dementia)

r.           Non-vascular causes of chronic brain syndrome (e.g., Pick`s disease,  

     Alzheimer`s disease, Korsakoff`s disease)

s.          Multiple sclerosis

t.           Migraine or cluster headaches

u.          Meningitis

v.          Closed head and/or spinal cord injury

w.         Myocardial infarction

x.          Cardiogenic shock

y.          Sickle cell crisis or hematuria

z.          Radiation-induced cystitis, myelitis, enteritis, proctitis

aa.      Bone grafts or fracture healing (e.g., nonunion fractures)

bb.      Arthritic diseases

cc.       Ophthalmologic diseases (including diabetic retinopathy, retinal

     detachment, Central retinal artery occlusion, radiation injury to the optic  

     nerve, glaucoma, Keratoendotheliosis)

dd.      Hepatic necrosis

ee.      Lepromatous leprosy

ff.         Arthritis

gg.      Avascular necrosis of the femoral head

hh.      Cystic acne

ii.           Melisma

jj.          Actinic skin damage

kk.       Lyme disease

ll.           Cerebral palsy

mm.       Reflex sympathetic dystrophy (complex regional pain syndrome).

nn.      Necrotizing arachnidism

oo.      Bell`s palsy

pp.      Legg-Calve Perthes disease

qq.      Crohn`s disease

rr.         Osteoporosis

ss.       Cancer

tt.         HIV infection

uu.      Facial neuritis

vv.       Tinnitus

ww.         Interstitial cystitis.

4.  HBOT is not covered for the following conditions, as the safety of HBOT for these conditions has not been established.

a.          Untreated pneumothorax

b.          Concurrent administration of doxorubicin, cisplatin, or disulfiram

c.          Premature infants (birth prior to 37 weeks gestation).

5.  Topical HBOT administered to the open wound in small limb-encasing devices is considered experimental and investigational because its efficacy has not been established through controlled clinical trials.

The literature states that HBOT should not be a replacement for other standard successful therapeutic measures. Depending on the response of the individual patient and the severity of the original problem, treatment may range from less than 1 week to several months` duration, the average being 2 to 4 weeks. HBOT treatment for more than 2 months is usually not necessary.

HBOT has been shown to be an effective method for treating diabetic foot wounds in carefully selected cases of lower extremity lesions. Although the results of multiple retrospective studies involving a significant number of patients have consistently indicated a high success rate in patients who had been refractory to other modes of therapy, several recent prospective, randomized studies have only supported the adjunctive role of systemic hyperbaric oxygen therapy in the treatment of non-healing infected deep lower extremity wounds in patients with diabetes. Such evidence is lacking, however, for superficial diabetic wounds and non-diabetic cutaneous, decubitus, and venous stasis ulcers.

Absolute contraindications to hyperbaric oxygen therapy include: untreated pneumothorax, concurrent administration of disulfiram (Antabuse); concurrent administration of the antineoplastic agents doxorubicin and cisplatinum; and administration to premature infants (due to risk of retrolental fibroplasia). Relative contraindications to the use of hyperbaric oxygen therapy include prior chest surgery, lung disease, viral infections, recent middle ear surgery, optic neuritis, seizure disorders, high fever, congenital spherocytosis, and claustrophobia.

Topical HBOT administered to the open wound in small limb-encasing devices is not systemic HBOT and its efficacy has not been established due to the lack of controlled clinical trials. In addition, in vitro evidence suggests that topical HBOT does not increase tissue oxygen tension beyond the superficial dermis. Examples of topical HBOT devices are TOPOX portable hyperbaric oxygen extremity and sacral chambers (Jersey City, NJ), Oxyboot and Oxyhealer from GWR Medical, L.L.P. (Chadds Ford, PA).

1. Arkansas BlueCross BlueShield, Coverage policy manual; Hyperbaric Oxygen Pressurization at: http://www.arkbluecross.com/members/ex_report.asp?ID=1997088
2. Centers for Medicare and Medicaid Services, National coverage determinations; hyperbaric oxygen therapy at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=20.29&ncd_version=2&show=all
3. The Undersea and Hyperbaric Medical Society (UHMS), Hyperbaric Oxygen Therapy Committee. Guidelines: Indications for Hyperbaric Oxygen. Kensington, MD: UHMS; 2000. Available at; http://www.uhms.org/Indications/indications.htm .
4. McDonagh M, Carson S, Ash J. Hyperbaric oxygen therapy for brain injury, cerebral palsy, and stroke. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2003.
5. Bennett M, Heard R. Hyperbaric oxygen therapy for multiple sclerosis (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
6. Juurlink DN, Stanbrook MB, McGuigan MA. Hyperbaric oxygen for carbon monoxide poisoning (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
7. Coulthard P, Esposito M, Worthington HV, Jokstad A. Interventions for replacing missing teeth: Hyperbaric oxygen therapy for irradiated patients who require dental implants (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
8. Greaves I, Porter K, Smith JE, et al. Consensus statement on the early management of crush injury and prevention of crush syndrome. J R Army Med Corps. 2003; 149(4):255-259.
9. Patterson J. Hyperbaric oxygen therapy for central retinal artery occlusion. Bazian Ltd., eds. London, UK: Wessex Institute for Health Research and Development, University of Southampton; 2002.
10. Dent THS. Hyperbaric oxygen therapy for carbon monoxide poisoning. Bazian Ltd., eds. London, UK: Wessex Institute for Health Research and Development, University of Southampton; 2002.
11. Ball CM. Hyperbaric oxygen therapy for multiple sclerosis. Bazian Ltd., eds. London, UK: Wessex Institute for Health Research and Development, University of Southampton; 2002
12. Bisset F. Hyperbaric oxygen therapy in people with necrotizing fasciitis or Fournier`s gangrene. Bazian Ltd., eds. London, UK: Wessex Institute for Health Research and Development, University of Southampton; 2002.
13. Kranke P, Bennett M, Roeckl-Wiedmann I, Debus S. Hyperbaric oxygen therapy for chronic wounds (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd.
14. Villanueva E, Bennett MH, Wasiak J, Lehm JP. Hyperbaric oxygen therapy for thermal burns (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd.
15. Lawson R. Hyperbaric oxygen for osteomyelitis. Bazian Ltd., eds. London, UK: Wessex Institute for Health Research and Development, University of Southampton; 2003.
16. van Ophoven A, Rossbach G, Oberpenning F, Hertle L. Hyperbaric oxygen for the treatment of interstitial cystitis: Long-term results of a prospective pilot study. Eur Urol. 2004; 46(1):108-113.
17. Bennett MH, Kertesz T, Yeung P. Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus. Cochrane Database Syst Rev. 2005 ;( 1): CD004739.
18. Phillips JS, Jones SEM. Hyperbaric oxygen as an adjuvant treatment for malignant otitis external [Protocol for Cochrane Review]. Cochrane Database Syst Rev. 2004 ;( 1): CD004617.
19. Bennett M, Jepson N. Hyperbaric oxygen therapy for acute coronary syndrome [Protocol for Cochrane Review]. Cochrane Database Syst Rev. 2004 ;( 3):CD004818.
20. Bennett MH, Wasiak J, French C, et al. Hyperbaric oxygen therapy for acute ischemic stroke [Protocol for Cochrane Review]. Cochrane Database Syst Rev. 2004 ;( 2): CD004954.
21. Bennett M, Babul S, Best TM, et al. Hyperbaric oxygen therapy for delayed onset muscle soreness and closed soft tissue injury [Protocol for Cochrane Review]. Cochrane Database Syst Rev. 2004 ;( 2): CD004713.
22. Bennett MH, Feldmeier J, Hampson N, et al. Hyperbaric oxygen therapy for late radiation tissue injury [Protocol for Cochrane Review]. Cochrane Database Syst Rev. 2004 ;( 2):CD005005.
23. Bennett MH, Stanford R, Turner R. Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non-union. Cochrane Database Syst Rev. 2005 ;( 1): CD004712.
24. Bennett MH, Trytko B, Jonker B. Hyperbaric oxygen therapy for the adjunctive treatment of traumatic brain injury. Cochrane Database Syst Rev. 2004 ;( 4):CD004609.
25. Bennett M, Feldmeier J, Smee R, Milross C. Hyperbaric oxygenation for tumor sensitization to radiotherapy [Protocol for Cochrane Review]. Cochrane Database Syst Rev. 2004 ;( 1):CD005007.
26. Lueck C, McIlwaine G. Interventions for idiopathic intracranial hypertension. Cochrane Database Syst Rev. 2002 ;( 3):CD003434.

Addendum:

Effective 01/01/2017: First two units of hyperbaric oxygen therapy do not require pre-authorization, to allow immediate use in medical emergencies in the ER or hospital.