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Hyperbaric Oxygen Therapy

Section: Miscellaneous
Effective Date: March 01, 2020
Last Reviewed: January 22, 2020

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
  • 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 individualswho 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
  • Hasa wound classified as Wagner grade III or higher; and
  • Hasfailed 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.

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

Topical hyperbaric oxygen therapy is considered experimental/investigational and therefore non-covered.

Scientific evidence does not support the efficacy and safety.

Procedure Codes

A4575  

Diagnosis Codes

A42.0 A42.1 A42.2 A42.81 A42.82 A42.89 A42.9
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
E10.618 E10.620 E10.621 E10.622 E10.628 E10.630 E10.638
E10.69 E11.52 E11.59 E11.621 E11.622 E11.628 E11.630
E11.638 E11.69 E13.51 E13.52 E13.59 E13.618 E13.621
E13.622 E13.628 E13.630 E13.638 E13.69 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
I73.00 I73.01 I73.1 I73.81 I73.89 I73.9 I74.2
I74.3 I74.4 I74.5 I79.8 I96 K52.0 K62.7
L08.0 L08.1 L08.81 L08.89 L08.9 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 L98.418 L98.428 L98.498
L98.8 M27.2 M27.8 M46.20 M46.21 M46.22 M46.23
M46.24 M46.25 M46.26 M46.27 M46.28 M72.6 M86.00
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
M86.08 M86.09 M86.10 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 M86.18 M86.19 M86.20 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 M86.28
M86.29 M86.30 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 M86.38 M86.39 M86.40 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 M86.48 M86.49
M86.50 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 M86.58 M86.59 M86.60 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 M86.68 M86.69 M86.8X0
M86.8X1 M86.8X2 M86.8X3 M86.8X4 M86.8X5 M86.8X6 M86.8X7
M86.8X8 M86.8X9 M86.9 M90.80 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 M90.88 M90.89 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 S67.190A 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 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 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 S97.101A 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 S97.80XA S97.80XD
S97.81XA S97.81XD S97.82XA S97.82XD T57.3X1A T57.3X1D T57.3X1S
T57.3X2A T57.3X2D T57.3X2S T57.3X3A T57.3X3D T57.3X3S T57.3X4A
T57.3X4D T57.3X4S T58.01XA 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 T58.2X1A 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 T58.91XA 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 T70.20XA T70.20XD T70.20XS
T70.29XA T70.29XD T70.29XS T70.3XXA T70.3XXD T70.3XXS T79.0XXA
T79.0XXD T79.0XXD T79.0XXS 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

Table: 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.

Professional Statements and Societal Positions Guidelines

NA

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