Hyperbaric Oxygen Therapy Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 10|01|2019 POLICY LAST REVIEWED: 10|01|2025 OVERVIEW Hyperbaric oxygen therapy (HBOT) involves breathing 100% oxygen at pressures between 1.5 and 3.0 atmospheres. It is generally applied systemically with the patient inside a hyperbaric chamber. HBOT can also be applied topically; ie, the body part to be treated is isolated (eg, in an inflatable bag and exposed to pure oxygen). HBOT has been investigated for various conditions that have potential to respond to increased oxygen delivery to tissue. MEDICAL CRITERIA Not applicable
PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage Plans and Commercial Products Hyperbaric oxygen therapy (HBOT) is medically necessary when filed with a covered indication. Hyperbaric oxygen therapy (HBOT) is not covered for Medicare Advantage Plans and not medically necessary for Commercial Products for all other indications as the evidence is insufficient to determine the effects of the technology on health outcomes. Medicare Advantage Plans
Topical hyperbaric oxygen therapy is not covered as the evidence is insufficient to determine the effects of the technology on health outcomes. Commercial Products Topical hyperbaric oxygen therapy is not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes. COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate section of the Benefit Booklet, Evidence of Coverage, Subscriber Agreement for applicable medical treatment coverage.
BACKGROUND Hyperbaric Oxygen Therapy Hyperbaric oxygen therapy (HBOT) is a technique for delivering higher pressures of oxygen to tissue. Two methods of administration are available: topical and systemic. Topical Hyperbaric Oxygen Therapy Topical hyperbaric therapy is a technique of delivering 100% oxygen directly to an open, moist wound at a pressure slightly higher than atmospheric pressure. It is hypothesized that the high concentrations of oxygen diffuse directly into the wound to increase the local cellular oxygen tension, which in turn promotes wound healing. Devices consist of an appliance to enclose the wound area (frequently an extremity) and a source of oxygen; conventional oxygen tanks may be used. The appliances may be disposable and may be used without supervision in the home by well-trained patients. Topical hyperbaric therapy has been investigated as a treatment of skin ulcerations resulting from diabetes, venous stasis, postsurgical infection, gangrenous lesion, decubitus ulcers, amputations, skin graft, burns, or frostbite. Medical Coverage Policy | Hyperbaric Oxygen Therapy

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

Systemic Hyperbaric Oxygen Therapy In systemic or large hyperbaric oxygen chambers, the patient is entirely enclosed in a pressure chamber and breathes oxygen at a pressure greater than 1 atmosphere (the pressure of oxygen at sea level). Thus, this technique relies on systemic circulation to deliver highly oxygenated blood to the target site, typically a wound. Systemic HBOT can be used to treat systemic illness, such as air or gas embolism, carbon monoxide poisoning, or clostridial gas gangrene. Treatment may be carried out either in a monoplace chamber pressurized with pure oxygen or in a larger, multiplace chamber pressurized with compressed air, in which case the patient receives pure oxygen by mask, head tent, or endotracheal tube.

The evidence for the use of systemic HBOT in individuals with nonhealing diabetic wounds of the lower extremities, acute traumatic ischemia, soft-tissue radiation necrosis (eg, radiation enteritis, cystitis, proctitis), osteoradionecrosis (ie, pre- and posttreatment), planned dental surgery (non-implant-related) of an irradiated jaw, gas gangrene, and profound anemia with exceptional blood loss when blood transfusion is impossible or must be delayed includes systematic reviews and/or recommendations from the Undersea and Hyperbaric Medical Society’s (UHMS). Relevant outcomes include overall survival, symptoms, change in disease status, and functional outcomes. For all indications in the PICO note, evidence and/or USMS guidelines support use of HBOT. The evidence is sufficient to determine qualitatively that the technology results in a meaningful improvement in health outcomes.

The evidence for the use of systemic HBOT in individuals with any condition other than those specified in the policy are not medically necessary as the available studies do not demonstrate that HBOT improves relevant outcomes. The evidence is insufficient to determine the effects of the technology on health outcomes.

The evidence for the use of topical HBOT in individuals who might respond to increased oxygen delivery to tissues includes primarily of case series and case reports. Relevant outcomes are symptoms and change in disease status. A systematic review identified 3 RCTs on the use of topical HBOT for chronic wound healing. The results showed topical oxygen therapy improved wound healing, but there was heterogeneity in the trial populations and treatment regimens. There is a small RCT on topical HBOT for diabetic foot ulcers; it showed no differences in outcomes between the treatment and control group. No controlled studies on topical HBOT for patients with burns or infections were identified. The data are insufficient to draw conclusions about the effect on the net health outcome.

CODING: Medicare Advantage Plans and Commercial Products The following code(s) are medically necessary when filed with a covered ICD-10 Diagnosis Code* listed below:
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

Note: The covered diagnosis must be filed on the claim line to ensure correct claim processing

*2025 Covered Diagnosis Code List for Hyperbaric Oxygen Therapy

The following HCPCS code(s) are not covered for Medicare Advantage Plans and not medically necessary for Commercial Products: A4575 Topical hyperbaric oxygen chamber, disposable E0446 Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories

RELATED POLICIES Not applicable

PUBLISHED

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

Provider Update, December 2025 Provider Update, October 2024 Provider Update, April 2023 Provider Update, April 2022 Provider Update, May 2021

REFERENCES

1. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29). 2017; https://www.cms.gov/medicare-coverage- database/details/ncd-details.aspx?ncdid=12&ver=3. Accessed July 10, 2024.
2. The Centers for Medicare and Medicaid Services. Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L33797): https://www.cms.gov/medicare-coverage- database/view/lcd.aspx?lcdid=33797&ver=50&bc=0
3. Undersea and Hyperbaric Medical Society. Hyperbaric Oxygen Therapy Indications, 15th Edition. Best Publishing Company (North Palm Beach, FL). 2023.
4. Gornik HL, Aronow HD, Goodney PP, et al. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Jun 11 2024; 149(24): e1313-e1410. PMID 38743805
5. United States Navy Dive Manual, Revision 7. 2016
6. Sadri RA, Cooper JS. Hyperbaric, complications. NCBI Bookshelf 2017; https://www.ncbi.nlm.nih.gov/books/NBK459191/. Accessed July 7, 2024.
7. U.S. Food and Drug Administration. Hyperbaric Oxygen Therapy: Don't Be Misled. 2013; https://www.talkingaboutthescience.com/studies/FDA2013.pdf. Accessed July 10, 2024.
8. de Smet GHJ, Kroese LF, Menon AG, et al. Oxygen therapies and their effects on wound healing. Wound Repair Regen. Aug 2017; 25(4): 591-608. PMID 28783878
9. Sharma R, Sharma SK, Mudgal SK, et al. Efficacy of hyperbaric oxygen therapy for diabetic foot ulcer, a systematic review and meta-analysis of controlled clinical trials. Sci Rep. Jan 26 2021; 11(1): 2189. PMID 33500533
10. Kranke P, Bennett MH, Martyn-St James M, et al. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev. Jun 24 2015; 2015(6): CD004123. PMID 26106870
11. Elraiyah T, Tsapas A, Prutsky G, et al. A systematic review and meta-analysis of adjunctive therapies in diabetic foot ulcers. J Vasc Surg. Feb 2016; 63(2 Suppl): 46S-58S.e1-2. PMID 26804368
12. Buckley NA, Juurlink DN, Isbister G, et al. Hyperbaric oxygen for carbon monoxide poisoning. Cochrane Database Syst Rev. Apr 13 2011; 2011(4): CD002041. PMID 21491385
13. Nakajima M, Aso S, Matsui H, et al. Hyperbaric oxygen therapy and mortality from carbon monoxide poisoning: A nationwide observational study. Am J Emerg Med. Feb 2020; 38(2): 225-230. PMID 30797609
14. Bennett MH, Feldmeier J, Hampson NB, et al. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database Syst Rev. Apr 28 2016; 4(4): CD005005. PMID 27123955
15. Borab Z, Mirmanesh MD, Gantz M, et al. Systematic review of hyperbaric oxygen therapy for the treatment of radiation-induced skin necrosis. J Plast Reconstr Aesthet Surg. Apr 2017; 70(4): 529-538. PMID 28081957
16. Ravi P, Vaishnavi D, Gnanam A, et al. The role of hyperbaric oxygen therapy in the prevention and management of radiation-induced complications of the head and neck - a systematic review of literature. J Stomatol Oral Maxillofac Surg. Dec 2017; 118(6): 359-362. PMID 28838774
17. Savvidou OD, Kaspiris A, Bolia IK, et al. Effectiveness of Hyperbaric Oxygen Therapy for the Management of Chronic Osteomyelitis: A Systematic Review of the Literature. Orthopedics. Jul 01 2018; 41(4): 193-199. PMID 30035798
18. Maynor ML, Moon RE, Camporesi EM, et al. Chronic osteomyelitis of the tibia: treatment with hyperbaric oxygen and autogenous microsurgical muscle transplantation. J South Orthop Assoc. 1998; 7(1): 43-57. PMID 9570731

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

19. Davis JC, Heckman JD, DeLee JC, et al. Chronic non-hematogenous osteomyelitis treated with adjuvant hyperbaric oxygen. J Bone Joint Surg Am. Oct 1986; 68(8): 1210-7. PMID 3771602
20. Chen CE, Ko JY, Fu TH, et al. Results of chronic osteomyelitis of the femur treated with hyperbaric oxygen: a preliminary report. Chang Gung Med J. Feb 2004; 27(2): 91-7. PMID 15095953
21. Chen CE, Shih ST, Fu TH, et al. Hyperbaric oxygen therapy in the treatment of chronic refractory osteomyelitis: a preliminary report. Chang Gung Med J. Feb 2003; 26(2): 114-21. PMID 12718388
22. Chen CY, Lee SS, Chan YS, et al. Chronic refractory tibia osteomyelitis treated with adjuvent hyperbaric oxygen: a preliminary report. Changgeng Yi Xue Za Zhi. Jun 1998; 21(2): 165-71. PMID 9729650
23. Villanueva E, Bennett MH, Wasiak J, et al. Hyperbaric oxygen therapy for thermal burns. Cochrane Database Syst Rev. 2004; 2004(3): CD004727. PMID 15266540
24. Eskes A, Vermeulen H, Lucas C, et al. Hyperbaric oxygen therapy for treating acute surgical and traumatic wounds. Cochrane Database Syst Rev. Dec 16 2013; (12): CD008059. PMID 24343585
25. Dauwe PB, Pulikkottil BJ, Lavery L, et al. Does hyperbaric oxygen therapy work in facilitating acute wound healing: a systematic review. Plast Reconstr Surg. Feb 2014; 133(2): 208e-215e. PMID 24469192
26. Zhou YY, Liu W, Yang YJ, et al. Use of hyperbaric oxygen on flaps and grafts in China: analysis of studies in the past 20 years. Undersea Hyperb Med. 2014; 41(3): 209-16. PMID 24984315
27. Freiberger JJ, Padilla-Burgos R, McGraw T, et al. What is the role of hyperbaric oxygen in the management of bisphosphonate-related osteonecrosis of the jaw: a randomized controlled trial of hyperbaric oxygen as an adjunct to surgery and antibiotics. J Oral Maxillofac Surg. Jul 2012; 70(7): 1573-
28. PMID 22698292
29. Levett D, Bennett MH, Millar I. Adjunctive hyperbaric oxygen for necrotizing fasciitis. Cochrane Database Syst Rev. Jan 15 2015; 1(1): CD007937. PMID 25879088
30. Hedetoft M, Bennett MH, Hyldegaard O. Adjunctive hyperbaric oxygen treatment for necrotising soft- tissue infections: A systematic review and meta-analysis. Diving Hyperb Med. Mar 31 2021; 51(1): 34-43. PMID 33761539
31. Bennett MH, Lehm JP, Jepson N. Hyperbaric oxygen therapy for acute coronary syndrome. Cochrane Database Syst Rev. Jul 23 2015; 2015(7): CD004818. PMID 26202854
32. Bennett MH, Weibel S, Wasiak J, et al. Hyperbaric oxygen therapy for acute ischaemic stroke. Cochrane Database Syst Rev. Nov 12 2014; (11): CD004954. PMID 25387992
33. Efrati S, Fishlev G, Bechor Y, et al. Hyperbaric oxygen induces late neuroplasticity in post stroke patients--randomized, prospective trial. PLoS One. 2013; 8(1): e53716. PMID 23335971
34. Holland NJ, Bernstein JM, Hamilton JW. Hyperbaric oxygen therapy for Bell's palsy. Cochrane Database Syst Rev. Feb 15 2012; 2012(2): CD007288. PMID 22336830
35. Wang F, Wang Y, Sun T, et al. Hyperbaric oxygen therapy for the treatment of traumatic brain injury: a meta-analysis. Neurol Sci. May 2016; 37(5): 693-701. PMID 26746238
36. Crawford C, Teo L, Yang E, et al. Is Hyperbaric Oxygen Therapy Effective for Traumatic Brain Injury? A Rapid Evidence Assessment of the Literature and Recommendations for the Field. J Head Trauma Rehabil. 2017; 32(3): E27-E37. PMID 27603765
37. Bennett MH, Trytko B, Jonker B. Hyperbaric oxygen therapy for the adjunctive treatment of traumatic brain injury. Cochrane Database Syst Rev. Dec 12 2012; 12: CD004609. PMID 23235612
38. Hart BB, Weaver LK, Gupta A, et al. Hyperbaric oxygen for mTBI-associated PCS and PTSD: Pooled analysis of results from Department of Defense and other published studies. Undersea Hyperb Med. BIMA 2019; 46(3): 353-383. PMID 31394604
39. mTBI mechanisms of action of HBO2 for persistent post-concussive symptoms. U.S. National Library of Medicine. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT01611194. Accessed April 28,
41. Hart BB, Wilson SH, Churchill S, et al. Extended follow-up in a randomized trial of hyperbaric oxygen for persistent post-concussive symptoms. Undersea Hyperb Med. BIMA 2019; 46(3): 313-327. PMID 31394601
42. Churchill S, Deru K, Weaver LK, et al. Adverse events and blinding in two randomized trials of hyperbaric oxygen for persistent post-concussive symptoms. Undersea Hyperb Med. BIMA 2019; 46(3): 331-340. PMID 31394602
43. Weaver LK, Churchill S, Wilson SH, et al. A composite outcome for mild traumatic brain injury in trials of hyperbaric oxygen. Undersea Hyperb Med. BIMA 2019; 46(3): 341-352. PMID 31394603

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

42. Hyperbaric oxygen therapy (HBO2) for persistent post-concussive symptoms after mild traumatic brain injury (mTBI) (HOPPS). U.S. National Library of Medicine. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT01306968. Updated September 5, 2014. Accessed April 28,
44. McCurdy J, Siw KCK, Kandel R, et al. The Effectiveness and Safety of Hyperbaric Oxygen Therapy in Various Phenotypes of Inflammatory Bowel Disease: Systematic Review With Meta-analysis. Inflamm Bowel Dis. Mar 30 2022; 28(4): 611-621. PMID 34003289
45. Dulai PS, Buckey JC, Raffals LE, et al. Hyperbaric oxygen therapy is well tolerated and effective for ulcerative colitis patients hospitalized for moderate-severe flares: a phase 2A pilot multi-center, randomized, double-blind, sham-controlled trial. Am J Gastroenterol. Oct 2018; 113(10): 1516-1523. PMID 29453383
46. Dulai PS, Raffals LE, Hudesman D, et al. A phase 2B randomised trial of hyperbaric oxygen therapy for ulcerative colitis patients hospitalised for moderate to severe flares. Aliment Pharmacol Ther. Sep 2020; 52(6): 955-963. PMID 32745306
47. Pagoldh M, Hultgren E, Arnell P, et al. Hyperbaric oxygen therapy does not improve the effects of standardized treatment in a severe attack of ulcerative colitis: a prospective randomized study. Scand J Gastroenterol. Sep 2013; 48(9): 1033-40. PMID 23879825
48. Bennett MH, Kertesz T, Perleth M, et al. Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus. Cochrane Database Syst Rev. Oct 17 2012; 10: CD004739. PMID 23076907
49. Rhee TM, Hwang D, Lee JS, et al. Addition of Hyperbaric Oxygen Therapy vs Medical Therapy Alone for Idiopathic Sudden Sensorineural Hearing Loss: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg. Dec 01 2018; 144(12): 1153-1161. PMID 30267033
50. Joshua TG, Ayub A, Wijesinghe P, et al. Hyperbaric Oxygen Therapy for Patients With Sudden Sensorineural Hearing Loss: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg. Jan 01 2022; 148(1): 5-11. PMID 34709348
51. Eryigit B, Ziylan F, Yaz F, et al. The effectiveness of hyperbaric oxygen in patients with idiopathic sudden sensorineural hearing loss: a systematic review. Eur Arch Otorhinolaryngol. Dec 2018; 275(12): 2893-2904. PMID 30324404
52. Cavaliere M, De Luca P, Scarpa A, et al. Combination of Hyperbaric Oxygen Therapy and Oral Steroids for the Treatment of Sudden Sensorineural Hearing Loss: Early or Late?. Medicina (Kaunas). Oct 10 2022; 58(10). PMID 36295581
53. Bennett M, Best TM, Babul S, et al. Hyperbaric oxygen therapy for delayed onset muscle soreness and closed soft tissue injury. Cochrane Database Syst Rev. Oct 19 2005; 2005(4): CD004713. PMID 16235376
54. Xiong T, Chen H, Luo R, et al. Hyperbaric oxygen therapy for people with autism spectrum disorder (ASD). Cochrane Database Syst Rev. Oct 13 2016; 10(10): CD010922. PMID 27737490
55. Sampanthavivat M, Singkhwa W, Chaiyakul T, et al. Hyperbaric oxygen in the treatment of childhood autism: a randomised controlled trial. Diving Hyperb Med. Sep 2012; 42(3): 128-33. PMID 22987458
56. Rizzato A, D'Alessandro N, Berenci E, et al. Effect of mild hyperbaric oxygen therapy on children diagnosed with autism. Undersea Hyperb Med. 2018; 45(6): 639-645. PMID 31158930
57. Lacey DJ, Stolfi A, Pilati LE. Effects of hyperbaric oxygen on motor function in children with cerebral palsy. Ann Neurol. Nov 2012; 72(5): 695-703. PMID 23071074
58. Collet JP, Vanasse M, Marois P, et al. Hyperbaric oxygen for children with cerebral palsy: a randomised multicentre trial. HBO-CP Research Group. Lancet. Feb 24 2001; 357(9256): 582-6. PMID 11558483
59. Long Y, Tan J, Nie Y, et al. Hyperbaric oxygen therapy is safe and effective for the treatment of sleep disorders in children with cerebral palsy. Neurol Res. Mar 2017; 39(3): 239-247. PMID 28079475
60. Xiao Y, Wang J, Jiang S, et al. Hyperbaric oxygen therapy for vascular dementia. Cochrane Database Syst Rev. Jul 11 2012; (7): CD009425. PMID 22786527
61. Villeirs L, Tailly T, Ost P, et al. Hyperbaric oxygen therapy for radiation cystitis after pelvic radiotherapy: Systematic review of the recent literature. Int J Urol. Feb 2020; 27(2): 98-107. PMID 31617263
62. Gothard L, Haviland J, Bryson P, et al. Randomised phase II trial of hyperbaric oxygen therapy in patients with chronic arm lymphoedema after radiotherapy for cancer. Radiother Oncol. Oct 2010; 97(1): 101-7. PMID 20605648

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 6 (401) 274-4848 WWW.BCBSRI.COM

62. Oscarsson N, Müller B, Rosén A, et al. Radiation-induced cystitis treated with hyperbaric oxygen therapy (RICH-ART): a randomised, controlled, phase 2-3 trial. Lancet Oncol. Nov 2019; 20(11): 1602-1614. PMID 31537473
63. Camporesi EM, Vezzani G, Bosco G, et al. Hyperbaric oxygen therapy in femoral head necrosis. J Arthroplasty. Sep 2010; 25(6 Suppl): 118-23. PMID 20637561
64. Bennett MH, French C, Schnabel A, et al. Normobaric and hyperbaric oxygen therapy for the treatment and prevention of migraine and cluster headache. Cochrane Database Syst Rev. Dec 28 2015; 2015(12): CD005219. PMID 26709672
65. Peng Z, Wang S, Huang X, et al. Effect of hyperbaric oxygen therapy on patients with herpes zoster. Undersea Hyperb Med. 2012; 39(6): 1083-7. PMID 23342765
66. Efrati S, Golan H, Bechor Y, et al. Hyperbaric oxygen therapy can diminish fibromyalgia syndrome-- prospective clinical trial. PLoS One. 2015; 10(5): e0127012. PMID 26010952
67. Yildiz S, Kiralp MZ, Akin A, et al. A new treatment modality for fibromyalgia syndrome: hyperbaric oxygen therapy. J Int Med Res. 2004; 32(3): 263-7. PMID 15174219
68. Bennett M, Heard R. Hyperbaric oxygen therapy for multiple sclerosis. CNS Neurosci Ther. Apr 2010; 16(2): 115-24. PMID 20415839
69. Bennett M, Feldmeier J, Smee R, et al. Hyperbaric oxygenation for tumour sensitisation to radiotherapy. Cochrane Database Syst Rev. Oct 19 2005; (4): CD005007. PMID 16235387
70. Bennett MH, Feldmeier J, Smee R, et al. Hyperbaric oxygenation for tumour sensitisation to radiotherapy. Cochrane Database Syst Rev. Apr 18 2012; 2012(4): CD005007. PMID 22513926
71. Heys SD, Smith IC, Ross JA, et al. A pilot study with long term follow up of hyperbaric oxygen pretreatment in patients with locally advanced breast cancer undergoing neo-adjuvant chemotherapy. Undersea Hyperb Med. 2006; 33(1): 33-43. PMID 16602255
72. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. Dec 2019; 50(12): e344-e418. PMID 31662037
73. Hingorani A, LaMuraglia GM, Henke P, et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. Feb 2016; 63(2 Suppl): 3S-21S. PMID 26804367
74. Huang ET, Mansouri J, Murad MH, et al. A clinical practice guideline for the use of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers. Undersea Hyperb Med. 2015; 42(3): 205-47. PMID 26152105

75. Chandrasekhar SS, Tsai Do BS, Schwartz SR, et al. Clinical Practice Guideline: Sudden Hearing Loss (Update). Otolaryngol Head Neck Surg. Aug 2019; 161(1_suppl): S1-S45. PMID 31369359

    i

    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS