Hyperbaric Oxygen Therapy Form

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Hyperbaric Oxygen Therapy Medical Guideline

Service: Hyperbaric Oxygen Therapy

PUM 250-0017

Medical Guideline Committee Approval Q2-06/2025 Effective Date 09/01/2025

Coverage for hyperbaric oxygen therapy may vary across plans. Refer to the member’s benefit plan document for coverage details.

Description: Hyperbaric oxygen therapy is a way to deliver high concentrations of oxygen to the tissues of the body. Hyperbaric oxygen therapy (HBOT) is used to treat certain conditions or diseases that may respond to increased tissue oxygenation when baseline tissue oxygen levels are too low for spontaneous healing. HBOT is indicated as primary treatment for some conditions; and for some treatment modalities it also may serve as an adjunctive therapy.

Indications of Coverage:

Systemic / large chamber hyperbaric oxygen is considered medically necessary when at least one of the following conditions is documented:

A. Actinomycosis or actinomycotic brain abscess (when the hyperbaric oxygen therapy is used along with conventional therapy for a disease that is not improved with antibiotics or surgery)

B. Acute carbon monoxide intoxication/poisoning

C. Acute central retinal artery occlusion

D. Acute peripheral arterial insufficiency

E. Acute thermal burn injury

F. Acute traumatic peripheral ischemia that threatens to cause loss of function of the limb, loss of the limb, or loss of life (such as a crush injury or compartment syndrome)

G. Emergent anemia in a patient unable or unwilling to receive red blood cell transfusion and one or more of the following:

1. Active hemolysis with rapidly progressive anemia

2. Active massive hemorrhage

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3. Severe signs or symptoms that have not improved with volume replacement (e.g., tachycardia, hypotension, chest pain, cognitive impairment)

   H. Chronic refractory osteomyelitis that has not responded to conventional medical and surgical treatment

   I. Compartment syndrome

   J. Cyanide poisoning

   K. Decompression sickness

   L. Gas embolism

   M. Gas gangrene

   N. Idiopathic sudden sensorineural hearing loss (ISSHL) as an adjunct to systemic steroids, (≥91 dB over at least three contiguous frequencies, occurring within three days, when initiated within 3 months of symptom onset: ideally within 2 weeks).

   O. Intracranial abscess with any of the following characteristics: multiple abscesses, deep or dominant location, immunocompromised host, contraindication to surgery or poor surgical candidate, and no clinical response or continued deterioration after surgical intervention (1 to 2 needle aspirates) and antibiotic therapy

   P. Osteoradionecrosis (when the hyperbaric oxygen therapy is used along with conventional treatment)

   Q. Progressive necrotizing infections (necrotizing fasciitis)

   R. Radiation induced:

4. Enteritis/ Proctitis or
5. Hemorrhagic cystitis or
6. Soft tissue and bone injury-head and neck (when the hyperbaric oxygen therapy is used in conjunction with conventional treatment) or

7. Osteonecrosis before and after extraction of tooth in irradiated field

   S. Skin grafts and flaps: Preparation and preservation of compromised grafts or flaps in which hypoxia or decreased perfusion has acutely compromised viability (not for primary management of wounds, maintenance of split thickness, or artificial skin substitutes)

   T. Treatment of crush injuries or severed limbs

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U. Diabetic wounds of the lower extremities in patients who meet ALL of the following (1 through 4 below):

1. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes

2. The wound has shown no improvement after a 30-day trial (minimum) of standard wound therapy that includes correction of any vascular conditions in the affected limb where possible, optimization of nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, appropriate off-loading, and necessary treatment to resolve any infection that might be present

3. The hyperbaric oxygen therapy is used in conjunction with standard wound care

4. Patient has a wound classified as Wagner Grade 3 or higher: a. Grade 3: deep ulcer with abscess or osteomyelitis
   b. Grade 4: gangrene to portion of forefoot c. Grade 5: extensive gangrene of foot

   Timeframes for approval:

   The frequency of treatments varies by conditions and severity. Acute conditions may warrant only one or two treatments, while chronic conditions may need more than thirty treatments. Acute infections and crush injuries may initially be treated 2-3 times per day in the inpatient setting.

    Note: If criteria are met, treatment may be approved up to a maximum of one month (30 days) from the start of treatment. Inpatient days of treatment are included in the 30-day maximum limit.

    Approval for further treatment will require documentation (with serial ruler / photographic measurement) of the effectiveness of the previous month’s treatments and physician progress note for each date of service the physician was present during treatment.

   Limitations of Coverage:

   Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

   A. Review health plan and endorsements for exclusions and prior authorization or benefit requirements.

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B. If requested/used for a condition or diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If requested/used for a condition or diagnosis that is listed in the Indications of Coverage; but the criteria (see Indications of coverage A through U) are not met, it will be considered not medically necessary.

D. Topical oxygen therapy (TOT) of any type (i.e., continuous TOT [CTOT] and hyperbaric TOT [HTOT]) is considered experimental, investigational, and unproven to affect health outcomes, as there is insufficient peer-reviewed scientific literature supporting its effectiveness.

E. Limb-encasing hyperbaric oxygen devices will be considered experimental, investigational, and unproven to affect health outcomes

F. Use of low-pressure fabric hyperbaric chambers will be considered experimental, investigational, and unproven to affect health outcomes when used for any diagnosis or condition other than acute altitude (mountain) sickness. These devices are FDA-approved only for acute altitude (mountain) sickness (and only when compressed with air).

G. Hyperbaric oxygen therapy is considered investigational for any of the following conditions as there is insufficient peer-reviewed scientific literature supporting the effectiveness of hyperbaric oxygen therapy in individuals with these conditions (list is not considered all-inclusive):

1. Acute cerebral edema

2. Acute or chronic cerebral vascular insufficiency

3. Acute thermal and chemical pulmonary damage (for example, smoke inhalation with pulmonary insufficiency)

4. Aerobic septicemia

5. Anaerobic septicemia and infection other than clostridial myositis and myonecrosis (gas gangrene)

6. Anemia –other than for the indications listed above in Indications of Coverage

7. Arterial ulcers

8. Arthritic diseases

9. Autism- (often considered an exclusion of the member health plan)

10. Bell’s Palsy

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11. Cancer of head, neck, or uterine cervix

12. Cardiogenic shock

13. Cerebral Palsy in children

14. Chronic Fatigue Syndrome

15. Chronic peripheral vascular insufficiency

16. Coronary Artery Disease

17. Cutaneous, decubitus, and stasis ulcers

18. Femoral Head Necrosis

19. Fibromyalgia

20. Fracture Healing

21. Frostbite

22. Hearing loss other than as described in the Indications of Coverage above

23. Hepatic necrosis

24. Ischemic stroke

25. Lyme Disease

26. Malignant Otitis Externa (MOE; an aggressive non-cancer otitis externa infection with spread to the temporal bone)

27. Medication-related osteonecrosis of jaw

28. Meningioma

29. Migraine and Cluster Headache

30. Multiple Sclerosis

31. Myocardial infarction

32. Nonvascular causes of chronic brain syndrome (for example, Pick’s disease, Alzheimer’s disease, Korsakoff’s disease)

33. Organ storage

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34. Organ transplantation

35. Otitis media/ uncomplicated otitis external

36. Post-COVID conditions

37. Pulmonary emphysema

38. Radiation induced lymphedema

39. Radiation induced neurologic injury

40. Radiation induced retinopathy

41. Retinitis pigmentosa

42. Senility

43. Sickle cell anemia

44. Skin burns (thermal)

45. Systemic aerobic infection

46. Tetanus

47. Traumatic Brain Injury or post concussive syndrome

48. Ulcerative Colitis

49. Vascular dementia

50. Venous ulcers

    Documentation Required:

    • Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
    • Medical record information (including continued need/use if applicable) and medical necessity (including serial ruler/photographic measurement for wound treatment). • Correct coding for the item/service that meets all the coding guidelines.

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Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

Hyperbaric oxygen treatment is considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

State mandates, laws or benchmark supersede this medical guideline.

Guideline Review History:

Implemented 07/15/15, 10/01/16, 10/01/17, 10/01/18, 07/01/19, 09/01/20, 05/01/21, 09/01/22, 09/01/23, 04/01/24, 09/01/25 Medical Guideline Committee Approval 06/13/14, 06/12/15, 06/03/16, 06/16/17, 06/15/18, 03/15/19, 03/26/20, 04/29/21, 04/28/22, 04/27/23, 03/28/24, 06/26/25 Reviewed

06/13/14, 06/12/15, 06/03/16, 06/16/17, 06/15/18, 03/15/19, 03/26/20, 04/29/21, 04/28/22, 04/27/23, 03/28/24, 06/26/25 Revised 06/12/15, 06/03/16, 06/16/17, 06/15/18, 03/15/19, 03/26/20, 04/29/21, 04/28/22 Developed

 Note: For review/revision history prior to 2014 see previous Medical Guideline

Approved by the Medical Director

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Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Code Description 99183 PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL ATTENDANCE AND SUPERVISION OF HYPERBARIC OXYGEN THERAPY, PER SESSION G0277 HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL Code Description 0413 RESPIRATORY SERVICES - HYPERBARIC OXYGEN THERAPY A4575 TOPICAL HYPERBARIC OXYGEN CHAMBER, DISPOSABLE