Hyperbaric Oxygen Therapy

Policy ID: Z-3-042

Section: Miscellaneous

Effective Date: March 01, 2020

Revised Date: July 11, 2022

Revision Effective Date: September 05, 2022

Last Reviewed: July 26, 2023

Applies To: Commercial and Medicaid Expansion

Description

Hyperbaric oxygen (HBO) therapy is a treatment in which the entire body is exposed to oxygen under increased atmospheric pressure. Full-body HBO therapy occurs in a single or multiple chambers with 100% systemic oxygen that has a pressurization of at least 1.4 atmospheres.

Criteria

HBO therapy may be considered medically necessary for ANY of the following:

Actinomycosis refractory to antibiotics and surgical treatment; or
Anemia with exceptional blood loss; or
Carbon monoxide intoxication (acute); or
Chronic refractory osteomyelitis; or
Crush injuries and suturing of severed limbs, when loss of function, limb or life is threatened; or
Cyanide poisoning; or
Decompression illness; or
Gas embolism; or
Gas gangrene; or
Idiopathic sudden sensorineural hearing loss (SSHL)
- SSHL greater than 30 dB affecting greater than three (3) consecutive frequencies of pure-tone thresholds; and
- when member has failed oral and intra-tympanic steroids; and
- HBOT is initiated within three (3) months after onset
Inflammatory bowel disease (IBD) meeting ALL the following:
- Severe fistulizing disease; and
- Disease progression of Crohn’s, ulcerative colitis, or pouchitis, despite being on maximal medical therapy indicated by use of at least two (2) separate classes of a biological agent in combination with an immunomodulator, unless the individual is unable to tolerate a particular class of medication; and
- Individual is established with an IBD specialist and the IBD specialist attests no other therapies with be beneficial; or
Necrotizing fasciitis; or
Osteoradionecrosis as an adjunct to conventional treatment; or
Peripheral arterial insufficiency (acute); or
Preparation and preservation of compromised skin grafts; or
- 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 (e.g., radiation enteritis, cystitis, proctitis); or
Traumatic peripheral ischemia (acute), when loss of function, limb, or life is threatened; or
Prophylactic pre-and post-treatment for member undergoing dental surgery of a radiated jaw.
For any indication not listed in the coverage criteria above, HBO therapy is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

99183

G0277

HBO therapy may be considered medically necessary for the treatment of diabetic wounds of the lower extremities in individuals who meet EITHER of the following criteria:

Has Type I or Type II diabetes and has a lower extremity wound that is due to diabetes; or
Has a wound classified as Wagner grade III or higher; and
Has failed an adequate course of standard wound therapy:
- The use of HBO therapy may be considered medically necessary as an adjunctive therapy after there are no measurable signs of healing for greater than or equal to 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 greater than or equal to 30 treatment sessions. Wounds must be evaluated every 30 days during administration of HBO therapy. Measurable signs of healing must be demonstrated within 30 treatment sessions for continued HBO therapy.

Wagner Classification of Diabetic Foot Ulcer

Grade 0

No ulcer in a high risk foot.

Grade 1

Superficial ulcer involving the full skin thickness but not underlying tissues.

Grade 2

Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation.

Grade 3

Deep ulcer with cellulitis or abscess formation, often with osteomyelitis.

Grade 4

Localized gangrene.

Grade 5

Extensive gangrene involving the whole foot.

For any indication not listed in the coverage criteria above, HBO therapy is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

99183

G0277

Topical hyperbaric oxygen therapy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature

Procedure Codes

A4575

Diagnosis Codes

A42.0

A42.1

A42.2

A42.9

A42.81

A42.82

A42.89

A48.0

B47.1

B47.9

B78.1

D50.0

D62

E08.52

E08.621

E08.622

E09.52

E09.621

E09.622

E10.52

E10.59

E10.69

E10.618

E10.620

E10.621

E10.622

E10.628

E10.630

E10.638

E11.52

E11.59

E11.69

E11.621

E11.622

E11.628

E11.630

E11.638

E13.51

E13.52

E13.59

E13.69

E13.618

E13.621

E13.622

E13.628

E13.630

E13.638

E83.2

I70.231

I70.232

I70.233

I70.234

I70.235

I70.238

I70.239

I70.241

I70.242

I70.243

I70.244

I70.245

I70.248

I70.249

I70.331

I70.332

I70.333

I70.334

I70.335

I70.338

I70.339

I70.341

I70.342

I70.343

I70.344

I70.345

I70.348

I70.349

I70.361

I70.362

I70.363

I70.368

I70.369

I70.431

I70.432

I70.433

I70.434

I70.435

I70.438

I70.439

I70.441

I70.442

I70.443

I70.444

I70.445

I70.448

I70.449

I70.461

I70.462

I70.463

I70.468

I70.469

I70.531

I70.532

I70.533

I70.534

I70.535

I70.538

I70.539

I70.541

I70.542

I70.543

I70.544

I70.545

I70.548

I70.549

I70.561

I70.562

I70.563

I70.568

I70.569

I70.631

I70.632

I70.633

I70.634

I70.635

I70.638

I70.639

I70.641

I70.642

I70.643

I70.644

I70.645

I70.648

I70.649

I70.731

I70.732

I70.733

I70.734

I70.735

I70.738

I70.739

I70.741

I70.742

I70.743

I70.744

I70.745

I70.748

I70.749

I73.1

I73.9

I73.00

I73.01

I73.81

I73.89

I74.2

I74.3

I74.4

I74.5

I79.8

I96

K50.013

K50.018

K50.019

K50.113

K50.118

K50.119

K50.813

K50.818

K50.819

K50.913

K50.918

K50.919

K51.513

K51.514

K51.518

K51.519

K51.811

K51.812

K51.813

K51.814

K51.818

K51.819

K51.911

K51.912

K51.913

K51.914

K51.918

K51.919

K52.0

K62.7

K91.850

K91.858

L08.0

L08.1

L08.9

L08.81

L08.89

L59.8

L59.9

L88

L92.8

L97.101

L97.102

L97.103

L97.104

L97.108

L97.109

L97.111

L97.112

L97.113

L97.114

L97.118

L97.119

L97.121

L97.122

L97.123

L97.124

L97.128

L97.129

L97.201

L97.202

L97.203

L97.204

L97.208

L97.209

L97.211

L97.212

L97.213

L97.214

L97.218

L97.219

L97.221

L97.222

L97.223

L97.224

L97.228

L97.229

L97.301

L97.302

L97.303

L97.304

L97.308

L97.309

L97.311

L97.312

L97.313

L97.314

L97.318

L97.319

L97.321

L97.322

L97.323

L97.324

L97.328

L97.329

L97.401

L97.402

L97.403

L97.404

L97.408

L97.409

L97.411

L97.412

L97.413

L97.414

L97.418

L97.419

L97.421

L97.422

L97.423

L97.424

L97.428

L97.429

L97.501

L97.502

L97.503

L97.504

L97.508

L97.509

L97.511

L97.512

L97.513

L97.514

L97.518

L97.519

L97.521

L97.522

L97.523

L97.524

L97.528

L97.529

L97.801

L97.802

L97.803

L97.804

L97.808

L97.809

L97.811

L97.812

L97.813

L97.814

L97.818

L97.819

L97.821

L97.822

L97.823

L97.824

L97.828

L97.829

L97.901

L97.902

L97.903

L97.904

L97.908

L97.909

L97.911

L97.912

L97.913

L97.914

L97.918

L97.919

L97.921

L97.922

L97.923

L97.924

L97.928

L97.929

L98.0

L98.3

L98.8

L98.418

L98.428

L98.498

M27.2

M27.8

M46.20

M46.21

M46.22

M46.23

M46.24

M46.25

M46.26

M46.27

M46.28

M72.6

M86.8X0

M86.8X1

M86.8X2

M86.8X3

M86.8X4

M86.8X5

M86.8X6

M86.8X7

M86.8X8

M86.8X9

M86.9

M86.00

M86.08

M86.09

M86.10

M86.18

M86.19

M86.20

M86.28

M86.29

M86.30

M86.38

M86.39

M86.40

M86.48

M86.49

M86.50

M86.58

M86.59

M86.60

M86.68

M86.69

M86.011

M86.012

M86.019

M86.021

M86.022

M86.029

M86.031

M86.032

M86.039

M86.041

M86.042

M86.049

M86.051

M86.052

M86.059

M86.061

M86.062

M86.069

M86.071

M86.072

M86.079

M86.111

M86.112

M86.119

M86.121

M86.122

M86.129

M86.131

M86.132

M86.139

M86.141

M86.142

M86.149

M86.151

M86.152

M86.159

M86.161

M86.162

M86.169

M86.171

M86.172

M86.179

M86.211

M86.212

M86.219

M86.221

M86.222

M86.229

M86.231

M86.232

M86.239

M86.241

M86.242

M86.249

M86.251

M86.252

M86.259

M86.261

M86.262

M86.269

M86.271

M86.272

M86.279

M86.311

M86.312

M86.319

M86.321

M86.322

M86.329

M86.331

M86.332

M86.339

M86.341

M86.342

M86.349

M86.351

M86.352

M86.359

M86.361

M86.362

M86.369

M86.371

M86.372

M86.379

M86.411

M86.412

M86.419

M86.421

M86.422

M86.429

M86.431

M86.432

M86.439

M86.441

M86.442

M86.449

M86.451

M86.452

M86.459

M86.461

M86.462

M86.469

M86.471

M86.472

M86.479

M86.511

M86.512

M86.519

M86.521

M86.522

M86.529

M86.531

M86.532

M86.539

M86.541

M86.542

M86.549

M86.551

M86.552

M86.559

M86.561

M86.562

M86.569

M86.571

M86.572

M86.579

M86.611

M86.612

M86.619

M86.621

M86.622

M86.629

M86.631

M86.632

M86.639

M86.641

M86.642

M86.649

M86.651

M86.652

M86.659

M86.661

M86.662

M86.669

M86.671

M86.672

M86.679

M90.80

M90.88

M90.89

M90.811

M90.812

M90.819

M90.821

M90.822

M90.829

M90.831

M90.832

M90.839

M90.841

M90.842

M90.849

M90.851

M90.852

M90.859

M90.861

M90.862

M90.869

M90.871

M90.872

M90.879

N30.40

N30.41

R57.1

R57.8

S35.511A

S35.511D

S35.512A

S35.512D

S35.513A

S35.513D

S45.001A

S45.001D

S45.002A

S45.002D

S45.009A

S45.009D

S45.011A

S45.011D

S45.012A

S45.012D

S45.019A

S45.019D

S45.091A

S45.091D

S45.092A

S45.092D

S45.099A

S45.099D

S45.101A

S45.101D

S45.102A

S45.102D

S45.109A

S45.109D

S45.111A

S45.111D

S45.112A

S45.112D

S45.119A

S45.119D

S45.191A

S45.191D

S45.192A

S45.192D

S45.199A

S45.199D

S45.201A

S45.201D

S45.202A

S45.202D

S45.209A

S45.209D

S45.211A

S45.211D

S45.212A

S45.212D

S45.219A

S45.219D

S45.291A

S45.291D

S45.292A

S45.292D

S45.299A

S45.299D

S47.1XXA

S47.1XXD

S47.2XXA

S47.2XXD

S47.9XXA

S47.9XXD

S57.00XA

S57.00XD

S57.01XA

S57.01XD

S57.02XA

S57.02XD

S57.80XA

S57.80XD

S57.81XA

S57.81XD

S57.82XA

S57.82XD

S67.00XA

S67.00XD

S67.01XA

S67.01XD

S67.02XA

S67.02XD

S67.10XA

S67.10XD

S67.20XA

S67.20XD

S67.21XA

S67.21XD

S67.22XA

S67.22XD

S67.30XA

S67.30XD

S67.31XA

S67.31XD

S67.32XA

S67.32XD

S67.40XA

S67.40XD

S67.41XA

S67.41XD

S67.42XA

S67.42XD

S67.90XA

S67.90XD

S67.91XA

S67.91XD

S67.92XA

S67.92XD

S67.190A

S67.190D

S67.191A

S67.191D

S67.192A

S67.192D

S67.193A

S67.193D

S67.194A

S67.194D

S67.195A

S67.195D

S67.196A

S67.196D

S67.197A

S67.197D

S67.198A

S67.198D

S75.001A

S75.001D

S75.002A

S75.002D

S75.009A

S75.009D

S75.011A

S75.011D

S75.012A

S75.012D

S75.019A

S75.019D

S75.021A

S75.021D

S75.022A

S75.022D

S75.029A

S75.029D

S75.091A

S75.091D

S75.092A

S75.092D

S75.099A

S75.099D

S77.00XA

S77.00XD

S77.01XA

S77.01XD

S77.02XA

S77.02XD

S77.10XA

S77.10XD

S77.11XA

S77.11XD

S77.12XA

S77.12XD

S77.20XA

S77.20XD

S77.21XA

S77.21XD

S77.22XA

S77.22XD

S85.001A

S85.001D

S85.002A

S85.002D

S85.009A

S85.009D

S85.011A

S85.011D

S85.012A

S85.012D

S85.019A

S85.019D

S85.091A

S85.091D

S85.092A

S85.092D

S85.099A

S85.099D

S85.501A

S85.502A

S85.509A

S85.511A

S85.512A

S85.519A

S85.591A

S85.592A

S85.599A

S87.00XA

S87.00XD

S87.01XA

S87.01XD

S87.02XA

S87.02XD

S87.80XA

S87.80XD

S87.81XA

S87.81XD

S87.82XA

S87.82XD

S97.00XA

S97.00XD

S97.01XA

S97.01XD

S97.02XA

S97.02XD

S97.80XA

S97.80XD

S97.81XA

S97.81XD

S97.82XA

S97.82XD

S97.101A

S97.101D

S97.102A

S97.102D

S97.109A

S97.109D

S97.111A

S97.111D

S97.112A

S97.112D

S97.119A

S97.119D

S97.121A

S97.121D

S97.122A

S97.122D

S97.129A

S97.129D

T57.3X1A

T57.3X1D

T57.3X1S

T57.3X2A

T57.3X2D

T57.3X2S

T57.3X3A

T57.3X3D

T57.3X3S

T57.3X4A

T57.3X4D

T57.3X4S

T58.2X1A

T58.2X1D

T58.2X1S

T58.2X2A

T58.2X2D

T58.2X2S

T58.2X3A

T58.2X3D

T58.2X3S

T58.2X4A

T58.2X4D

T58.2X4S

T58.8X1A

T58.8X1D

T58.8X1S

T58.8X2A

T58.8X2D

T58.8X2S

T58.8X3A

T58.8X3D

T58.8X3S

T58.8X4A

T58.8X4D

T58.8X4S

T58.01XA

T58.01XD

T58.01XS

T58.02XA

T58.02XD

T58.02XS

T58.03XA

T58.03XD

T58.04XA

T58.04XD

T58.11XA

T58.11XD

T58.12XA

T58.12XD

T58.12XS

T58.13XA

T58.13XD

T58.13XS

T58.14XA

T58.14XD

T58.14XS

T58.91XA

T58.91XD

T58.91XS

T58.92XA

T58.92XD

T58.92XS

T58.93XA

T58.93XD

T58.93XS

T58.94XA

T58.94XD

T58.94XS

T65.0X1A

T65.0X1D

T65.0X1S

T65.0X2A

T65.0X2D

T65.0X2S

T65.0X3A

T65.0X3D

T65.0X3S

T65.0X4A

T65.0X4D

T65.0X4S

T66.XXXA

T66.XXXD

T66.XXXS

T70.3XXA

T70.3XXD

T70.3XXS

T70.20XA

T70.20XD

T70.20XS

T70.29XA

T70.29XD

T70.29XS

T79.0XXA

T79.0XXD

T79.0XXS

T79.6XXD

T80.0XXA

T80.0XXD

T86.820

T86.821

T86.822

T86.828

T86.829

T87.0X1

T87.0X2

T87.0X9

T87.1X1

T87.1X2

T87.1X9

T87.2

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 topical as E/I called out in policy

Internal Medical Policy Committee 1-19-2021 Annual Review -

Expanded an indication, and
Added multiple diagnosis codes: K50.013, K50.018, K50.019, K50.113, K50.118, K50.119, K50.813, K50.818, K50.819, K50.913, K50.918, K50.919, K51.513, K51.514, K51.518, K51.519, K51.811, K51.812, K51.813, K51.814, K51.818, K51.819, K51.911, K51.912, K51.913, K51.914, K51.918, K51.919, K91.850, K91.858

Internal Medical Policy Committee 5-20-2021 Annual Review

Internal Medical Policy Committee 3-23-2022 Revision

Added Idiopathic sudden sensorineural hearing loss (SSHL) and criteria for this.

Internal Medical Policy Committee 7-21-2022 Revision

Updated with clarifying language.

Internal Medical Policy Committee 7-26-2023 Annual Review-no changes in criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: Z-3-041

Section: Miscellaneous

Effective Date: March 01, 2020

Revised Date: February 22, 2022

Revision Effective Date: May 02, 2022

Last Reviewed: March 23, 2022

Archived Date: September 04, 2022

Applies To: Commercial and Medicaid Expansion

Description

Criteria

HBO therapy may be considered medically necessary for ANY of the following:

Actinomycosis refractory to antibiotics and surgical treatment; or
Anemia with exceptional blood loss; or
Carbon monoxide intoxication (acute); or
Chronic refractory osteomyelitis; or
Crush injuries and suturing of severed limbs, when loss of function, limb or life is threatened; or
Cyanide poisoning; or
Decompression illness; or
Gas embolism; or
Gas gangrene; or
Inflammatory bowel disease (IBD) meeting ALL the following:
- Severe fistuliziing disease; and
- Disease progression of Crohn’s, ulcerative colitis, or pouchitis, despite being on maximal medical therapy indicated by use of at least two (2) separate classes of a biological agent in combination with an immunomodulator, unless the individual is unable to tolerate a particular class of medication; and
- Individual is established with an IBD specialist and the IBD specialist attests no other therapies with be beneficial; or
Idiopathic sudden sensorineural hearing loss (SSHL)
- SSHL greater than 30 dB affecting greater than three (3) consecutive frequencies of pure-tone thresholds; and
- when member has failed oral and intra-tympanic steroids; and
- HBOT is initiated within three (3) months after onset
Necrotizing fasciitis; or
Osteoradionecrosis as an adjunct to conventional treatment; or
Peripheral arterial insufficiency (acute); or
Preparation and preservation of compromised skin grafts; or
- 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 (e.g., radiation enteritis, cystitis, proctitis); or
Traumatic peripheral ischemia (acute), when loss of function, limb, or life is threatened; or
Prophylactic pre-and post-treatment for member undergoing dental surgery of a radiated jaw.

The use of HBO therapy is considered experimental/investigational and, therefore, non-covered for any indication not listed in the coverage criteria above. Scientific evidence does not support the efficacy and safety.

Procedure Codes

99183

G0277

HBO therapy may be considered medically necessary for the treatment of diabetic wounds of the lower extremities in individuals who meet EITHER of the following criteria:

Has Type I or Type II diabetes and has a lower extremity wound that is due to diabetes; or
Has a wound classified as Wagner grade III or higher; and
Has failed an adequate course of standard wound therapy:
- The use of HBO therapy will be covered as an adjunctive therapy after there are no measurable signs of healing for greater than or equal to 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 greater than or equal to 30 consecutive days. Wounds must be evaluated 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 a 30-day treatment period.

Wagner Classification of Diabetic Foot Ulcer

Grade 0

No ulcer in a high risk foot.

Grade 1

Superficial ulcer involving the full skin thickness but not underlying tissues.

Grade 2

Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation.

Grade 3

Deep ulcer with cellulitis or abscess formation, often with osteomyelitis.

Grade 4

Localized gangrene.

Grade 5

Extensive gangrene involving the whole foot.

Procedure Codes

99183

G0277

Procedure Codes

A4575

Diagnosis Codes

A42.0

A42.1

A42.2

A42.9

A42.81

A42.82

A42.89

A48.0

B47.1

B47.9

B78.1

D50.0

D62

E08.52

E08.621

E08.622

E09.52

E09.621

E09.622

E10.52

E10.59

E10.69

E10.618

E10.620

E10.621

E10.622

E10.628

E10.630

E10.638

E11.52

E11.59

E11.69

E11.621

E11.622

E11.628

E11.630

E11.638

E13.51

E13.52

E13.59

E13.69

E13.618

E13.621

E13.622

E13.628

E13.630

E13.638

E83.2

I70.231

I70.232

I70.233

I70.234

I70.235

I70.238

I70.239

I70.241

I70.242

I70.243

I70.244

I70.245

I70.248

I70.249

I70.331

I70.332

I70.333

I70.334

I70.335

I70.338

I70.339

I70.341

I70.342

I70.343

I70.344

I70.345

I70.348

I70.349

I70.361

I70.362

I70.363

I70.368

I70.369

I70.431

I70.432

I70.433

I70.434

I70.435

I70.438

I70.439

I70.441

I70.442

I70.443

I70.444

I70.445

I70.448

I70.449

I70.461

I70.462

I70.463

I70.468

I70.469

I70.531

I70.532

I70.533

I70.534

I70.535

I70.538

I70.539

I70.541

I70.542

I70.543

I70.544

I70.545

I70.548

I70.549

I70.561

I70.562

I70.563

I70.568

I70.569

I70.631

I70.632

I70.633

I70.634

I70.635

I70.638

I70.639

I70.641

I70.642

I70.643

I70.644

I70.645

I70.648

I70.649

I70.731

I70.732

I70.733

I70.734

I70.735

I70.738

I70.739

I70.741

I70.742

I70.743

I70.744

I70.745

I70.748

I70.749

I73.1

I73.9

I73.00

I73.01

I73.81

I73.89

I74.2

I74.3

I74.4

I74.5

I79.8

I96

K50.013

K50.018

K50.019

K50.113

K50.118

K50.119

K50.813

K50.818

K50.819

K50.913

K50.918

K50.919

K51.513

K51.514

K51.518

K51.519

K51.811

K51.812

K51.813

K51.814

K51.818

K51.819

K51.911

K51.912

K51.913

K51.914

K51.918

K51.919

K52.0

K62.7

K91.850

K91.858

L08.0

L08.1

L08.9

L08.81

L08.89

L59.8

L59.9

L88

L92.8

L97.101

L97.102

L97.103

L97.104

L97.108

L97.109

L97.111

L97.112

L97.113

L97.114

L97.118

L97.119

L97.121

L97.122

L97.123

L97.124

L97.128

L97.129

L97.201

L97.202

L97.203

L97.204

L97.208

L97.209

L97.211

L97.212

L97.213

L97.214

L97.218

L97.219

L97.221

L97.222

L97.223

L97.224

L97.228

L97.229

L97.301

L97.302

L97.303

L97.304

L97.308

L97.309

L97.311

L97.312

L97.313

L97.314

L97.318

L97.319

L97.321

L97.322

L97.323

L97.324

L97.328

L97.329

L97.401

L97.402

L97.403

L97.404

L97.408

L97.409

L97.411

L97.412

L97.413

L97.414

L97.418

L97.419

L97.421

L97.422

L97.423

L97.424

L97.428

L97.429

L97.501

L97.502

L97.503

L97.504

L97.508

L97.509

L97.511

L97.512

L97.513

L97.514

L97.518

L97.519

L97.521

L97.522

L97.523

L97.524

L97.528

L97.529

L97.801

L97.802

L97.803

L97.804

L97.808

L97.809

L97.811

L97.812

L97.813

L97.814

L97.818

L97.819

L97.821

L97.822

L97.823

L97.824

L97.828

L97.829

L97.901

L97.902

L97.903

L97.904

L97.908

L97.909

L97.911

L97.912

L97.913

L97.914

L97.918

L97.919

L97.921

L97.922

L97.923

L97.924

L97.928

L97.929

L98.0

L98.3

L98.8

L98.418

L98.428

L98.498

M27.2

M27.8

M46.20

M46.21

M46.22

M46.23

M46.24

M46.25

M46.26

M46.27

M46.28

M72.6

M86.8X0

M86.8X1

M86.8X2

M86.8X3

M86.8X4

M86.8X5

M86.8X6

M86.8X7

M86.8X8

M86.8X9

M86.9

M86.00

M86.08

M86.09

M86.10

M86.18

M86.19

M86.20

M86.28

M86.29

M86.30

M86.38

M86.39

M86.40

M86.48

M86.49

M86.50

M86.58

M86.59

M86.60

M86.68

M86.69

M86.011

M86.012

M86.019

M86.021

M86.022

M86.029

M86.031

M86.032

M86.039

M86.041

M86.042

M86.049

M86.051

M86.052

M86.059

M86.061

M86.062

M86.069

M86.071

M86.072

M86.079

M86.111

M86.112

M86.119

M86.121

M86.122

M86.129

M86.131

M86.132

M86.139

M86.141

M86.142

M86.149

M86.151

M86.152

M86.159

M86.161

M86.162

M86.169

M86.171

M86.172

M86.179

M86.211

M86.212

M86.219

M86.221

M86.222

M86.229

M86.231

M86.232

M86.239

M86.241

M86.242

M86.249

M86.251

M86.252

M86.259

M86.261

M86.262

M86.269

M86.271

M86.272

M86.279

M86.311

M86.312

M86.319

M86.321

M86.322

M86.329

M86.331

M86.332

M86.339

M86.341

M86.342

M86.349

M86.351

M86.352

M86.359

M86.361

M86.362

M86.369

M86.371

M86.372

M86.379

M86.411

M86.412

M86.419

M86.421

M86.422

M86.429

M86.431

M86.432

M86.439

M86.441

M86.442

M86.449

M86.451

M86.452

M86.459

M86.461

M86.462

M86.469

M86.471

M86.472

M86.479

M86.511

M86.512

M86.519

M86.521

M86.522

M86.529

M86.531

M86.532

M86.539

M86.541

M86.542

M86.549

M86.551

M86.552

M86.559

M86.561

M86.562

M86.569

M86.571

M86.572

M86.579

M86.611

M86.612

M86.619

M86.621

M86.622

M86.629

M86.631

M86.632

M86.639

M86.641

M86.642

M86.649

M86.651

M86.652

M86.659

M86.661

M86.662

M86.669

M86.671

M86.672

M86.679

M90.80

M90.88

M90.89

M90.811

M90.812

M90.819

M90.821

M90.822

M90.829

M90.831

M90.832

M90.839

M90.841

M90.842

M90.849

M90.851

M90.852

M90.859

M90.861

M90.862

M90.869

M90.871

M90.872

M90.879

N30.40

N30.41

R57.1

R57.8

S35.511A

S35.511D

S35.512A

S35.512D

S35.513A

S35.513D

S45.001A

S45.001D

S45.002A

S45.002D

S45.009A

S45.009D

S45.011A

S45.011D

S45.012A

S45.012D

S45.019A

S45.019D

S45.091A

S45.091D

S45.092A

S45.092D

S45.099A

S45.099D

S45.101A

S45.101D

S45.102A

S45.102D

S45.109A

S45.109D

S45.111A

S45.111D

S45.112A

S45.112D

S45.119A

S45.119D

S45.191A

S45.191D

S45.192A

S45.192D

S45.199A

S45.199D

S45.201A

S45.201D

S45.202A

S45.202D

S45.209A

S45.209D

S45.211A

S45.211D

S45.212A

S45.212D

S45.219A

S45.219D

S45.291A

S45.291D

S45.292A

S45.292D

S45.299A

S45.299D

S47.1XXA

S47.1XXD

S47.2XXA

S47.2XXD

S47.9XXA

S47.9XXD

S57.00XA

S57.00XD

S57.01XA

S57.01XD

S57.02XA

S57.02XD

S57.80XA

S57.80XD

S57.81XA

S57.81XD

S57.82XA

S57.82XD

S67.00XA

S67.00XD

S67.01XA

S67.01XD

S67.02XA

S67.02XD

S67.10XA

S67.10XD

S67.20XA

S67.20XD

S67.21XA

S67.21XD

S67.22XA

S67.22XD

S67.30XA

S67.30XD

S67.31XA

S67.31XD

S67.32XA

S67.32XD

S67.40XA

S67.40XD

S67.41XA

S67.41XD

S67.42XA

S67.42XD

S67.90XA

S67.90XD

S67.91XA

S67.91XD

S67.92XA

S67.92XD

S67.190A

S67.190D

S67.191A

S67.191D

S67.192A

S67.192D

S67.193A

S67.193D

S67.194A

S67.194D

S67.195A

S67.195D

S67.196A

S67.196D

S67.197A

S67.197D

S67.198A

S67.198D

S75.001A

S75.001D

S75.002A

S75.002D

S75.009A

S75.009D

S75.011A

S75.011D

S75.012A

S75.012D

S75.019A

S75.019D

S75.021A

S75.021D

S75.022A

S75.022D

S75.029A

S75.029D

S75.091A

S75.091D

S75.092A

S75.092D

S75.099A

S75.099D

S77.00XA

S77.00XD

S77.01XA

S77.01XD

S77.02XA

S77.02XD

S77.10XA

S77.10XD

S77.11XA

S77.11XD

S77.12XA

S77.12XD

S77.20XA

S77.20XD

S77.21XA

S77.21XD

S77.22XA

S77.22XD

S85.001A

S85.001D

S85.002A

S85.002D

S85.009A

S85.009D

S85.011A

S85.011D

S85.012A

S85.012D

S85.019A

S85.019D

S85.091A

S85.091D

S85.092A

S85.092D

S85.099A

S85.099D

S85.501A

S85.502A

S85.509A

S85.511A

S85.512A

S85.519A

S85.591A

S85.592A

S85.599A

S87.00XA

S87.00XD

S87.01XA

S87.01XD

S87.02XA

S87.02XD

S87.80XA

S87.80XD

S87.81XA

S87.81XD

S87.82XA

S87.82XD

S97.00XA

S97.00XD

S97.01XA

S97.01XD

S97.02XA

S97.02XD

S97.80XA

S97.80XD

S97.81XA

S97.81XD

S97.82XA

S97.82XD

S97.101A

S97.101D

S97.102A

S97.102D

S97.109A

S97.109D

S97.111A

S97.111D

S97.112A

S97.112D

S97.119A

S97.119D

S97.121A

S97.121D

S97.122A

S97.122D

S97.129A

S97.129D

T57.3X1A

T57.3X1D

T57.3X1S

T57.3X2A

T57.3X2D

T57.3X2S

T57.3X3A

T57.3X3D

T57.3X3S

T57.3X4A

T57.3X4D

T57.3X4S

T58.2X1A

T58.2X1D

T58.2X1S

T58.2X2A

T58.2X2D

T58.2X2S

T58.2X3A

T58.2X3D

T58.2X3S

T58.2X4A

T58.2X4D

T58.2X4S

T58.8X1A

T58.8X1D

T58.8X1S

T58.8X2A

T58.8X2D

T58.8X2S

T58.8X3A

T58.8X3D

T58.8X3S

T58.8X4A

T58.8X4D

T58.8X4S

T58.01XA

T58.01XD

T58.01XS

T58.02XA

T58.02XD

T58.02XS

T58.03XA

T58.03XD

T58.04XA

T58.04XD

T58.11XA

T58.11XD

T58.12XA

T58.12XD

T58.12XS

T58.13XA

T58.13XD

T58.13XS

T58.14XA

T58.14XD

T58.14XS

T58.91XA

T58.91XD

T58.91XS

T58.92XA

T58.92XD

T58.92XS

T58.93XA

T58.93XD

T58.93XS

T58.94XA

T58.94XD

T58.94XS

T65.0X1A

T65.0X1D

T65.0X1S

T65.0X2A

T65.0X2D

T65.0X2S

T65.0X3A

T65.0X3D

T65.0X3S

T65.0X4A

T65.0X4D

T65.0X4S

T66.XXXA

T66.XXXD

T66.XXXS

T70.3XXA

T70.3XXD

T70.3XXS

T70.20XA

T70.20XD

T70.20XS

T70.29XA

T70.29XD

T70.29XS

T79.0XXA

T79.0XXD

T79.0XXS

T79.6XXD

T80.0XXA

T80.0XXD

T86.820

T86.821

T86.822

T86.828

T86.829

T87.0X1

T87.0X2

T87.0X9

T87.1X1

T87.1X2

T87.1X9

T87.2

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 topical as E/I called out in policy

Internal Medical Policy Committee 1-19-2021 Annual Review - expanded an indication, addition of multiple diagnosis codes:K50.013, K50.018, K50.019, K50.113, K50.118, K50.119, K50.813,K50.818, K50.819, K50.913, K50.918, K50.919, K51.513, K51.514,K51.518, K51.519, K51.811, K51.812, K51.813, K51.814, K51.818,K51.819, K51.911, K51.912, K51.913, K51.914, K51.918, K51.919,K91.850, K91.858

Internal Medical Policy Committee 5-20-2021 Annual Review

Internal Medical Policy Committee 3-23-2022 Revision added Idiopathic sudden sensorineural hearing loss (SSHL) and criteria for this.

Links

References (PDF)

Disclaimer

Our Partners in Health:
Members
Employers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121

Medical Policies Quick Search