Hyperbaric Oxygen Therapy Form

MEDICAL COVERAGE POLICY SERVICE: Hyperbaric Oxygen Therapy Policy Number: 044 Effective Date: 04/01/2026 Last Review: 03/26/2026 Next Review: 03/26/2027 Important note: Unless otherwise indicated, medical policies will apply to all lines of business. Medical necessity as defined by this policy does not ensure the benefit is covered. This medical policy does not replace existing federal or state rules and regulations for the applicable service or supply. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan documents. See the member plan specific benefit plan document for a complete description of plan benefits, exclusions, limitations, and conditions of coverage. In the event of a discrepancy, the plan document always supersedes the information in this policy SERVICE: Hyperbaric Oxygen Therapy (HBOT) PRIOR AUTHORIZATION: Not required POLICY: Please review the plan’s EOC (Evidence of Coverage) or Summary Plan Description (SPD) for coverage details. Note: Unless otherwise indicated (see below), this policy will apply to all lines of business. For Medicare plans, please refer to appropriate Medicare NCD (National Coverage Determination) NCD 20.29 Hyperbaric Oxygen Therapy or LCD (Local Coverage Determination) L37873 Topical Oxygen Therapy (Non-Texas LCD). If there are no applicable NCD or LCD criteria, use the criteria set forth below. “Medicare Administrative Contractors (MACs) acting within their respective jurisdictions may determine coverage of topical application of oxygen for chronic non-healing wounds.” LCD L37873 (Palmetto), “This A/B MAC has rendered the LCD for Topical Oxygen Therapy as non-covered” For Medicaid plans, please confirm coverage as outlined in the Texas Medicaid Provider Procedures Manual | TMHP (TMPPM). If there are no applicable criteria to guide medical necessity decision making in the TMPPM, use the criteria set forth below. BSWHP may consider HBOT medically necessary for the following indications, once other standard and conventional therapies have been unsuccessful:

1. Acute carbon monoxide intoxication
2. Decompression illness
3. Air or Gas embolism
4. Gas gangrene (clostridial myositis and myonecrosis)
5. Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened.
6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened.

MEDICAL COVERAGE POLICY SERVICE: Hyperbaric Oxygen Therapy Policy Number: 044 Effective Date: 04/01/2026 Last Review: 03/26/2026 Next Review: 03/26/2027

7. Acute peripheral arterial insufficiency
8. Progressive necrotizing infections (necrotizing fasciitis)
9. Preparation and preservation of compromised skin grafts (not for primary management of wounds)
10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management
11. Osteoradionecrosis as an adjunct to conventional treatment
12. Soft tissue radio-necrosis as an adjunct to conventional treatment
13. Carbon monoxide poisoning with exposure to cyanide – combination may have synergistic toxicity
14. Actinomycosis caused by Actinomyces Israelii that is refractory to conventional therapy, (antibiotics and surgical treatment)
15. Idiopathic sudden sensorineural hearing loss (ISSHL) when hyperbaric oxygen therapy (HBOT) is combined with steroid therapy within two weeks to 4 weeks of onset of ISSHL
16. Central retinal artery occlusion (including CaHA (calcium hydroxylapatite) cosmetic filler injection likely due to an embolism)
17. Symptomatic anemia when transfusion is not possible or delayed
18. Diabetic wounds of the lower extremities in patients who meet the following three criteria: a. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; b. Patient has a wound classified as Wagner grade III or higher Wagner classification system of wounds is defined as follows:
    • grade 0 = no open lesion;
    • grade 1 = superficial ulcer without penetration to deeper layers;
    • grade 2 = ulcer penetrates to tendon, bone, or joint;
    • grade 3 = lesion has penetrated deeper than grade 2 and there is abscess, osteomyelitis, plantar space abscess, or infection of the tendon and tendon sheaths;
    • grade 4 = wet or dry gangrene in the toes or forefoot;
    • grade 5 = gangrene involves the whole foot or such a percentage that no local procedures are possible and amputation (at least at the below the knee level) is indicated.) and c. Patient has failed an adequate course of standard wound therapy The use of HBO therapy is covered as adjunctive therapy only after there are no 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. Standard wound care in patients with diabetic wounds includes:
19. Assessment of a patient’s vascular status and correction of any vascular problems in the affected limb if possible
20. Optimization of nutritional status
21. Optimization of glucose control
22. Debridement by any means to remove devitalized tissue
23. Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings
24. Appropriate off-loading
25. Necessary treatment to resolve any infection that might be present

MEDICAL COVERAGE POLICY SERVICE: Hyperbaric Oxygen Therapy Policy Number: 044 Effective Date: 04/01/2026 Last Review: 03/26/2026 Next Review: 03/26/2027 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 therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. EXCLUSIONS: BSWHP considers the use of systemic HBOT unproven for the following conditions (not an all-inclusive list) because there is insufficient evidence in the medical literature establishing that systemic HBOT is more effective than conventional therapies:

1. Cutaneous, decubitus, and stasis ulcers
2. Chronic peripheral vascular insufficiency
3. Anaerobic septicemia and infection other than clostridial
4. Skin burns (thermal)
5. Senility
6. Myocardial infarction
7. Cardiogenic shock
8. Sickle cell anemia
9. Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency
10. Acute or chronic cerebral vascular insufficiency
11. Hepatic necrosis
12. Aerobic septicemia
13. Nonvascular causes of chronic brain syndrome (Pick's disease, Alzheimer's disease, Korsakoff's disease)
14. Tetanus
15. Systemic aerobic infection
16. Organ transplantation
17. Organ storage
18. Pulmonary emphysema
19. Exceptional blood loss anemia
20. Multiple Sclerosis
21. Arthritic Diseases
22. Acute cerebral edema
23. Autistic Spectrum Disorders

MEDICAL COVERAGE POLICY SERVICE: Hyperbaric Oxygen Therapy Policy Number: 044 Effective Date: 04/01/2026 Last Review: 03/26/2026 Next Review: 03/26/2027 Contraindications for HBO

1. Absolute - Untreated pneumothorax
2. Relative - a. Upper respiratory tract infection b. Emphysema with carbon dioxide retention c. Asymptomatic pulmonary lesions seen on chest x-ray •History of thoracic or ear surgery d. Uncontrolled hyperthermia e. Pregnancy f. Claustrophobia g. Seizure disorder BACKGROUND: HBOT involves the systemic administration of pure gaseous oxygen under pressures greater than one atmosphere in a specialized chamber. The goal of HBO therapy is to promote tissue healing through a combination of increasing hydrostatic pressure and elevation of the tissue oxygen tension, increasing cellularity and improving vascularity; and to reverse hypoxia, prevent tissue damage and reduce the incidence of delayed neurological effects. Common Adverse Events (occurring in >1% of treatments): Ear discomfort and middle ear barotrauma (most common, affecting 10-33% of patients). Reversible myopia and visual changes (affecting up to 12% of patients),Sinus barotrauma, Confinement anxiety/claustrophobia, Chest discomfort, Headache Uncommon but Serious Adverse Events (0.1% of treatments): Oxygen toxicity seizures (rare, self- limited, no permanent damage),Pneumothorax (extremely rare when protocols followed),Pulmonary oxygen toxicity (with prolonged or repeated exposure) MANDATES: None

MEDICAL COVERAGE POLICY SERVICE: Hyperbaric Oxygen Therapy Policy Number: 044 Effective Date: 04/01/2026 Last Review: 03/26/2026 Next Review: 03/26/2027 CODES: CPT Codes 99183 - Hyperbaric oxygen therapy G0277 - HBOT, full body chamber, 30m CPT Codes Not Covered HCPCS Codes Not Covered A4575 - Topical hyperbaric oxygen chamber, disposable E0446 - Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories ICD-10 Codes List of covered diagnoses, per NCD 20.29, can be found at NCD - Hyperbaric Oxygen Therapy (20.29) POLICY HISTORY: Status Date Action New 8/1/2010 New policy Reviewed 12/2/2011 Reviewed Reviewed 10/5/2012 Reviewed Reviewed 5/30/2013 No changes. Codes added Reviewed 5/22/2014 No changes Reviewed 5/28/2015 No changes Reviewed 6/09/2016 LCD language added and used for policy statement Reviewed 05/16/2017 No changes Reviewed 04/03/2018 No changes Reviewed 06/27/2019 Updated per NCD and LCD. Dx code list linked to policy Reviewed 07/30/2020 Added language for FirstCare use Reviewed 07/22/2021 No changes Reviewed 06/23/2022 Updated Medicare information Reviewed 07/27/2023 No changes Reviewed 04/08/2024 Formatting changes, added hyperlinks to CMS and TMPPM resources, beginning and ending note sections updated to align with CMS requirements and business entity changes

MEDICAL COVERAGE POLICY SERVICE: Hyperbaric Oxygen Therapy Policy Number: 044 Effective Date: 04/01/2026 Last Review: 03/26/2026 Next Review: 03/26/2027 Reviewed 03/10/2025 Ending note section updated to align with business entity changes. Updated 08/11/2025 Removed “Medicare NCD or LCD specific InterQual criteria may be used when available” Updated 03/26/2026 Updated inclusion and exclusion criteria. Updated contraindications and background. Updated hyperlink to Medicare NCD 20.29 REFERENCES: The following scientific references were utilized in the formulation of this medical policy. BSWHP will continue to review clinical evidence related to this policy and may modify it at a later date based upon the evolution of the published clinical evidence. Should additional scientific studies become available, and they are not included in the list, please forward the reference(s) to BSWHP so the information can be reviewed by the Medical Coverage Policy Committee (MCPC) and the Quality Improvement Committee (QIC) to determine if a modification of the policy is in order. 1.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. Accessed January 22, 2001.

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3. Caplan ES. Hyperbaric oxygen. Pediatr Infect Dis J. 2000;19(2):151-152.
4. Saunders P. Hyperbaric oxygen therapy in the management of carbon monoxide poisoning, osteoradionecrosis, burns, skin grafts and crush injury. DPHE Report No. 23. West Midlands Development and Evaluation Service Report. Birmingham, UK: West Midlands Health Technology Assessment Collaboration, University of Birmingham (Collaborative effort with Wessex Institute) (WMHTAC); April 2000.
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MEDICAL COVERAGE POLICY SERVICE: Hyperbaric Oxygen Therapy Policy Number: 044 Effective Date: 04/01/2026 Last Review: 03/26/2026 Next Review: 03/26/2027

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MEDICAL COVERAGE POLICY SERVICE: Hyperbaric Oxygen Therapy Policy Number: 044 Effective Date: 04/01/2026 Last Review: 03/26/2026 Next Review: 03/26/2027

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MEDICAL COVERAGE POLICY SERVICE: Hyperbaric Oxygen Therapy Policy Number: 044 Effective Date: 04/01/2026 Last Review: 03/26/2026 Next Review: 03/26/2027

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MEDICAL COVERAGE POLICY SERVICE: Hyperbaric Oxygen Therapy Policy Number: 044 Effective Date: 04/01/2026 Last Review: 03/26/2026 Next Review: 03/26/2027 Note: Health Plan, and Scott & White Care Plans dba Baylor Scott & White Care Plan. Insured PPO and EPO products are offered through Baylor Scott & White Insurance Company. Scott and White Health Plan dba Baylor Scott & White Health Plan serves as a third-party administrator for self-funded employer-sponsored plans. Baylor Scott & White Care Plan and Baylor Scott & White Insurance Company are wholly owned subsidiaries of Scott and White Health Plan. These companies are referred to collectively in this document as Baylor Scott & White Health Plan. RightCare STAR Medicaid is offered through Scott and White Health Plan in the Central Texas Medicaid Rural Service Area (MRSA); FirstCare STAR is offered through SHA LLC dba FirstCare Health Plans (FirstCare) in the Lubbock and West MRSA; and FirstCare CHIP is offered through FirstCare in the Lubbock Service