653 Form

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Medical Policy Hyperbaric Oxygen Therapy
Table of Contents
• Policy: Commercial • Description • Information Pertaining to All Policies
• Authorization Information • Policy History • References
• Coding Information

Policy Number: 653
BCBSA Reference Number: 2.01.04 (For Plan internal use only) NCD/LCD: N/A
Related Policies
None
Policy
Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Topical hyperbaric oxygen therapy is INVESTIGATIONAL.

Systemic hyperbaric oxygen pressurization may be MEDICALLY NECESSARY in the treatment of the conditions outlined in the Undersea & Hyperbaric Medical Society (UHMS) Hyperbaric Medicine Indications Manual.
• Non-healing diabetic wounds of the lower extremities in individuals who meet the following 3 criteria:
a. Individual has type I or type II diabetes and has a lower extremity wound that is due to diabetes, AND
b. Individual has a wound classified as Wagner grade 3* or higher, AND
c. Individual has no measurable signs of healing after 30 days of an adequate course of standard wound therapy.
• Acute traumatic ischemia e.g., crush injuries, reperfusion injury, compartment syndrome
• Decompression sickness • Gas embolism, acute • Cyanide poisoning, acute • Acute carbon monoxide poisoning • Soft-tissue radiation necrosis (e.g., radiation enteritis, cystitis, proctitis) and osteoradionecrosis • Pre- and post-treatment for individuals undergoing dental surgery (non-implant-related) of an irradiated jaw • Gas gangrene (i.e., clostridial myonecrosis) • Profound anemia with exceptional blood loss: only when blood transfusion is impossible or must be delayed
• Chronic refractory osteomyelitis

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• Compromised skin grafts or flaps • Progressive necrotizing soft tissue infections
• idiopathic sudden sensorineural hearing loss (SSNHL) when: o Hyperbaric oxygen therapy (HBOT) is combined with steroid therapy within 2 weeks of onset of SSNHL o Hyperbaric oxygen therapy (HBOT) is combined with steroid therapy as salvage within 1 month of onset of SSNHL; AND • Central retinal artery occlusion.

*The Wagner classification system of wounds is defined as: • 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, pyarthrosis, 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.

Systemic hyperbaric oxygen pressurization is INVESTIGATIONAL in the treatment of the following conditions:

• Acute peripheral arterial insufficiency (outside of other listed medically necessary indications involving arterial insufficiency)
• Acute coronary syndromes and as an adjunct to coronary interventions, including but not limited to, percutaneous coronary interventions and cardiopulmonary bypass • Acute ischemic stroke • Acute osteomyelitis • Acute surgical and traumatic wounds not meeting criteria specified in the medically necessary statement
• Acute thermal burns • Autism spectrum disorders • Bell’s palsy • Bisphosphonate-related osteonecrosis of the jaw • Bone grafts • Brown recluse spider bites • Carbon tetrachloride poisoning, acute • Cerebral edema, acute • Cerebral palsy • Cerebrovascular disease, acute (thrombotic or embolic) or chronic • Chronic arm lymphedema following radiotherapy for cancer • Chronic wounds, other than those in individuals with diabetes who meet the criteria specified in the medically necessary statement • Delayed onset muscle soreness • Demyelinating diseases, e.g., multiple sclerosis, amyotrophic lateral sclerosis • Early treatment (beginning at completion of radiation therapy) to reduce adverse effects of radiation therapy
• Fibromyalgia • Fracture healing • Herpes zoster • Hydrogen sulfide poisoning • Idiopathic femoral neck necrosis • In vitro fertilization

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• Inflammatory bowel disease (Crohn disease or ulcerative colitis) • Intra-abdominal and intracranial abscesses • Lepromatous leprosy • Meningitis • Mental illness (i.e., posttraumatic stress disorder, generalized anxiety disorder or depression) • Migraine • Motor dysfunction associated with stroke • Necrotizing soft-tissue infections • Pseudomembranous colitis (antimicrobial agent-induced colitis) • Pyoderma gangrenosum • Radiation myelitis • Radiation-induced injury in the head and neck, except as noted earlier in the medically necessary statement
• Refractory mycoses: mucormycosis, actinomycosis, canidiobolus coronato • Retinopathy, adjunct to scleral buckling procedures in individuals with sickle cell peripheral retinopathy and retinal detachment
• Sickle cell crisis and/or hematuria • Spinal cord injury • Traumatic brain injury • Tumor sensitization for cancer treatments, including but not limited to, radiotherapy or chemotherapy
• Vascular dementia.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.
Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity: CPT Codes CPT codes: Code Description 99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session

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HCPCS Codes HCPCS codes: Code Description G0277 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT, HCPCS and/or ICD Procedure codes above if medical necessity criteria are met: ICD-10-CM Diagnosis Coding ICD-10-CM diagnosis codes: Code Description A48.0 Gas gangrene D62 Acute posthemorrhagic anemia E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E10.621 Type 1 diabetes mellitus with foot ulcer E10.622 Type 1 diabetes mellitus with other skin ulcer E10.628 Type 1 diabetes mellitus with other skin complications E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E11.621 Type 2 diabetes mellitus with foot ulcer E11.622 Type 2 diabetes mellitus with other skin ulcer E11.628 Type 2 diabetes mellitus with other skin complications E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.59 Other specified diabetes mellitus with other circulatory complications E13.621 Other specified diabetes mellitus with foot ulcer E13.622 Other specified diabetes mellitus with other skin ulcer E13.628 Other specified diabetes mellitus with other skin complications H34.10 Central retinal artery occlusion, unspecified eye H34.11 Central retinal artery occlusion, right eye H34.12 Central retinal artery occlusion, left eye H34.13 Central retinal artery occlusion, bilateral H91.20 Sudden idiopathic hearing loss, unspecified ear H91.21 Sudden idiopathic hearing loss, right ear H91.22 Sudden idiopathic hearing loss, left ear H91.23 Sudden idiopathic hearing loss, bilateral I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh

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I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf I70.233 Atherosclerosis of native arteries of right leg with ulceration of ankle I70.234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower right leg I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf I70.243 Atherosclerosis of native arteries of left leg with ulceration of ankle I70.244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site I70.331 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of thigh I70.332 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of calf I70.333 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of ankle I70.334 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of heel and midfoot I70.335 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of foot I70.338 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of lower leg I70.339 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of unspecified site I70.341 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of thigh I70.342 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of calf I70.343 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of ankle I70.344 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of heel and midfoot I70.345 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of foot I70.348 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of lower leg I70.349 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of unspecified site I70.361 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, right leg I70.362 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, left leg I70.363 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, bilateral legs I70.368 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, other extremity I70.369 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, unspecified extremity

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I70.431 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of thigh I70.432 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of calf I70.433 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of ankle I70.434 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of heel and midfoot I70.435 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of foot I70.438 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of lower leg I70.439 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of unspecified site I70.441 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of thigh I70.442 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of calf I70.443 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of ankle I70.444 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of heel and midfoot I70.445 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of foot I70.448 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of lower leg I70.449 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of unspecified site I70.461 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, right leg I70.462 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, left leg I70.463 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, bilateral legs I70.468 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, other extremity I70.469 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, unspecified extremity I70.531 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of thigh I70.532 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of calf I70.533 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of ankle I70.534 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of heel and midfoot I70.535 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of foot I70.538 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of lower leg I70.539 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of unspecified site I70.541 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of thigh

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I70.542 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of calf I70.543 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of ankle I70.544 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of heel and midfoot I70.545 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of foot I70.548 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of lower leg I70.549 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of unspecified site I70.561 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, right leg I70.562 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, left leg I70.563 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, bilateral legs I70.568 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, other extremity I70.569 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, unspecified extremity I70.631 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of thigh I70.632 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of calf I70.633 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of ankle I70.634 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of heel and midfoot I70.635 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of foot I70.638 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of lower leg I70.639 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of unspecified site I70.641 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of thigh I70.642 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of calf I70.643 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of ankle I70.644 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of heel and midfoot I70.645 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other part of foot I70.648 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other part of lower leg I70.649 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of unspecified site I70.661 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, right leg I70.662 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, left leg I70.663 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, bilateral legs I70.668 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, other extremity

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I70.669 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, unspecified extremity I70.731 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of thigh I70.732 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of calf I70.733 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of ankle I70.734 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of heel and midfoot I70.735 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other part of foot I70.738 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other part of lower leg I70.739 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of unspecified site I70.741 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of thigh I70.742 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of calf I70.743 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of ankle I70.744 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of heel and midfoot I70.745 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other part of foot I70.748 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other part of lower leg I70.749 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of unspecified site I70.761 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, right leg I70.762 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, left leg I70.763 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, bilateral legs I70.768 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, other extremity I70.769 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, unspecified extremity I73.01 Raynaud's syndrome with gangrene I96 Gangrene, not elsewhere classified K62.7 Radiation proctitis L59.8 Other specified disorders of the skin and subcutaneous tissue related to radiation L59.9 Disorder of the skin and subcutaneous tissue related to radiation, unspecified L97.101 Non-pressure chronic ulcer of unspecified thigh limited to breakdown of skin L97.102 Non-pressure chronic ulcer of unspecified thigh with fat layer exposed L97.103 Non-pressure chronic ulcer of unspecified thigh with necrosis of muscle L97.104 Non-pressure chronic ulcer of unspecified thigh with necrosis of bone L97.105 Non-pressure chronic ulcer of unspecified thigh with muscle involvement without evidence of necrosis L97.106 Non-pressure chronic ulcer of unspecified thigh with bone involvement without evidence of necrosis L97.108 Non-pressure chronic ulcer of unspecified thigh with other specified severity L97.109 Non-pressure chronic ulcer of unspecified thigh with unspecified severity L97.111 Non-pressure chronic ulcer of right thigh limited to breakdown of skin L97.112 Non-pressure chronic ulcer of right thigh with fat layer exposed L97.113 Non-pressure chronic ulcer of right thigh with necrosis of muscle

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L97.114 Non-pressure chronic ulcer of right thigh with necrosis of bone L97.115 Non-pressure chronic ulcer of right thigh with muscle involvement without evidence of necrosis L97.116 Non-pressure chronic ulcer of right thigh with bone involvement without evidence of necrosis L97.118 Non-pressure chronic ulcer of right thigh with other specified severity L97.119 Non-pressure chronic ulcer of right thigh with unspecified severity L97.121 Non-pressure chronic ulcer of left thigh limited to breakdown of skin L97.122 Non-pressure chronic ulcer of left thigh with fat layer exposed L97.123 Non-pressure chronic ulcer of left thigh with necrosis of muscle L97.124 Non-pressure chronic ulcer of left thigh with necrosis of bone L97.125 Non-pressure chronic ulcer of left thigh with muscle involvement without evidence of necrosis L97.126 Non-pressure chronic ulcer of left thigh with bone involvement without evidence of necrosis L97.128 Non-pressure chronic ulcer of left thigh with other specified severity L97.129 Non-pressure chronic ulcer of left thigh with unspecified severity L97.201 Non-pressure chronic ulcer of unspecified calf limited to breakdown of skin L97.202 Non-pressure chronic ulcer of unspecified calf with fat layer exposed L97.203 Non-pressure chronic ulcer of unspecified calf with necrosis of muscle L97.204 Non-pressure chronic ulcer of unspecified calf with necrosis of bone L97.205 Non-pressure chronic ulcer of unspecified calf with muscle involvement without evidence of necrosis L97.206 Non-pressure chronic ulcer of unspecified calf with bone involvement without evidence of necrosis L97.208 Non-pressure chronic ulcer of unspecified calf with other specified severity L97.209 Non-pressure chronic ulcer of unspecified calf with unspecified severity L97.211 Non-pressure chronic ulcer of right calf limited to breakdown of skin L97.212 Non-pressure chronic ulcer of right calf with fat layer exposed L97.213 Non-pressure chronic ulcer of right calf with necrosis of muscle L97.214 Non-pressure chronic ulcer of right calf with necrosis of bone L97.215 Non-pressure chronic ulcer of right calf with muscle involvement without evidence of necrosis L97.216 Non-pressure chronic ulcer of right calf with bone involvement without evidence of necrosis L97.218 Non-pressure chronic ulcer of right calf with other specified severity L97.219 Non-pressure chronic ulcer of right calf with unspecified severity L97.221 Non-pressure chronic ulcer of left calf limited to breakdown of skin L97.222 Non-pressure chronic ulcer of left calf with fat layer exposed L97.223 Non-pressure chronic ulcer of left calf with necrosis of muscle L97.224 Non-pressure chronic ulcer of left calf with necrosis of bone L97.225 Non-pressure chronic ulcer of left calf with muscle involvement without evidence of necrosis L97.226 Non-pressure chronic ulcer of left calf with bone involvement without evidence of necrosis L97.228 Non-pressure chronic ulcer of left calf with other specified severity L97.229 Non-pressure chronic ulcer of left calf with unspecified severity L97.301 Non-pressure chronic ulcer of unspecified ankle limited to breakdown of skin L97.302 Non-pressure chronic ulcer of unspecified ankle with fat layer exposed L97.303 Non-pressure chronic ulcer of unspecified ankle with necrosis of muscle L97.304 Non-pressure chronic ulcer of unspecified ankle with necrosis of bone

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L97.305 Non-pressure chronic ulcer of unspecified ankle with muscle involvement without evidence of necrosis L97.306 Non-pressure chronic ulcer of unspecified ankle with bone involvement without evidence of necrosis L97.308 Non-pressure chronic ulcer of unspecified ankle with other specified severity L97.309 Non-pressure chronic ulcer of unspecified ankle with unspecified severity L97.311 Non-pressure chronic ulcer of right ankle limited to breakdown of skin L97.312 Non-pressure chronic ulcer of right ankle with fat layer exposed L97.313 Non-pressure chronic ulcer of right ankle with necrosis of muscle L97.314 Non-pressure chronic ulcer of right ankle with necrosis of bone L97.315 Non-pressure chronic ulcer of right ankle with muscle involvement without evidence of necrosis L97.316 Non-pressure chronic ulcer of right ankle with bone involvement without evidence of necrosis L97.318 Non-pressure chronic ulcer of right ankle with other specified severity L97.319 Non-pressure chronic ulcer of right ankle with unspecified severity L97.321 Non-pressure chronic ulcer of left ankle limited to breakdown of skin L97.322 Non-pressure chronic ulcer of left ankle with fat layer exposed L97.323 Non-pressure chronic ulcer of left ankle with necrosis of muscle L97.324 Non-pressure chronic ulcer of left ankle with necrosis of bone L97.325 Non-pressure chronic ulcer of left ankle with muscle involvement without evidence of necrosis L97.326 Non-pressure chronic ulcer of left ankle with bone involvement without evidence of necrosis L97.328 Non-pressure chronic ulcer of left ankle with other specified severity L97.329 Non-pressure chronic ulcer of left ankle with unspecified severity L97.401 Non-pressure chronic ulcer of unspecified heel and midfoot limited to breakdown of skin L97.402 Non-pressure chronic ulcer of unspecified heel and midfoot with fat layer exposed L97.403 Non-pressure chronic ulcer of unspecified heel and midfoot with necrosis of muscle L97.404 Non-pressure chronic ulcer of unspecified heel and midfoot with necrosis of bone L97.405 Non-pressure chronic ulcer of unspecified heel and midfoot with muscle involvement without evidence of necrosis L97.406 Non-pressure chronic ulcer of unspecified heel and midfoot with bone involvement without evidence of necrosis L97.408 Non-pressure chronic ulcer of unspecified heel and midfoot with other specified severity L97.409 Non-pressure chronic ulcer of unspecified heel and midfoot with unspecified severity L97.411 Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin L97.412 Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed L97.413 Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle L97.414 Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone L97.415 Non-pressure chronic ulcer of right heel and midfoot with muscle involvement without evidence of necrosis L97.416 Non-pressure chronic ulcer of right heel and midfoot with bone involvement without evidence of necrosis L97.418 Non-pressure chronic ulcer of right heel and midfoot with other specified severity L97.419 Non-pressure chronic ulcer of right heel and midfoot with unspecified severity L97.421 Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin L97.422 Non-pressure chronic ulcer of left heel and midfoot with fat layer exposed L97.423 Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle L97.424 Non-pressure chronic ulcer of left heel and midfoot with necrosis of bone

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L97.425 Non-pressure chronic ulcer of left heel and midfoot with muscle involvement without evidence of necrosis L97.426 Non-pressure chronic ulcer of left heel and midfoot with bone involvement without evidence of necrosis L97.428 Non-pressure chronic ulcer of left heel and midfoot with other specified severity L97.429 Non-pressure chronic ulcer of left heel and midfoot with unspecified severity L97.501 Non-pressure chronic ulcer of other part of unspecified foot limited to breakdown of skin L97.502 Non-pressure chronic ulcer of other part of unspecified foot with fat layer exposed L97.503 Non-pressure chronic ulcer of other part of unspecified foot with necrosis of muscle L97.504 Non-pressure chronic ulcer of other part of unspecified foot with necrosis of bone L97.505 Non-pressure chronic ulcer of other part of unspecified foot with muscle involvement without evidence of necrosis L97.506 Non-pressure chronic ulcer of other part of unspecified foot with bone involvement without evidence of necrosis L97.508 Non-pressure chronic ulcer of other part of unspecified foot with other specified severity L97.509 Non-pressure chronic ulcer of other part of unspecified foot with unspecified severity L97.511 Non-pressure chronic ulcer of other part of right foot limited to breakdown of skin L97.512 Non-pressure chronic ulcer of other part of right foot with fat layer exposed L97.513 Non-pressure chronic ulcer of other part of right foot with necrosis of muscle L97.514 Non-pressure chronic ulcer of other part of right foot with necrosis of bone L97.515 Non-pressure chronic ulcer of other part of right foot with muscle involvement without evidence of necrosis L97.516 Non-pressure chronic ulcer of other part of right foot with bone involvement without evidence of necrosis L97.518 Non-pressure chronic ulcer of other part of right foot with other specified severity L97.519 Non-pressure chronic ulcer of other part of right foot with unspecified severity L97.521 Non-pressure chronic ulcer of other part of left foot limited to breakdown of skin L97.522 Non-pressure chronic ulcer of other part of left foot with fat layer exposed L97.523 Non-pressure chronic ulcer of other part of left foot with necrosis of muscle L97.524 Non-pressure chronic ulcer of other part of left foot with necrosis of bone L97.525 Non-pressure chronic ulcer of other part of left foot with muscle involvement without evidence of necrosis L97.526 Non-pressure chronic ulcer of other part of left foot with bone involvement without evidence of necrosis L97.528 Non-pressure chronic ulcer of other part of left foot with other specified severity L97.529 Non-pressure chronic ulcer of other part of left foot with unspecified severity L97.801 Non-pressure chronic ulcer of other part of unspecified lower leg limited to breakdown of skin L97.802 Non-pressure chronic ulcer of other part of unspecified lower leg with fat layer exposed L97.803 Non-pressure chronic ulcer of other part of unspecified lower leg with necrosis of muscle L97.804 Non-pressure chronic ulcer of other part of unspecified lower leg with necrosis of bone L97.805 Non-pressure chronic ulcer of other part of unspecified lower leg with muscle involvement without evidence of necrosis L97.806 Non-pressure chronic ulcer of other part of unspecified lower leg with bone involvement without evidence of necrosis L97.808 Non-pressure chronic ulcer of other part of unspecified lower leg with other specified severity

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L97.809 Non-pressure chronic ulcer of other part of unspecified lower leg with unspecified severity L97.811 Non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin L97.812 Non-pressure chronic ulcer of other part of right lower leg with fat layer exposed L97.813 Non-pressure chronic ulcer of other part of right lower leg with necrosis of muscle L97.814 Non-pressure chronic ulcer of other part of right lower leg with necrosis of bone L97.815 Non-pressure chronic ulcer of other part of right lower leg with muscle involvement without evidence of necrosis L97.816 Non-pressure chronic ulcer of other part of right lower leg with bone involvement without evidence of necrosis L97.818 Non-pressure chronic ulcer of other part of right lower leg with other specified severity L97.819 Non-pressure chronic ulcer of other part of right lower leg with unspecified severity L97.821 Non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skin L97.822 Non-pressure chronic ulcer of other part of left lower leg with fat layer exposed L97.823 Non-pressure chronic ulcer of other part of left lower leg with necrosis of muscle L97.824 Non-pressure chronic ulcer of other part of left lower leg with necrosis of bone L97.825 Non-pressure chronic ulcer of other part of left lower leg with muscle involvement without evidence of necrosis L97.826 Non-pressure chronic ulcer of other part of left lower leg with bone involvement without evidence of necrosis L97.828 Non-pressure chronic ulcer of other part of left lower leg with other specified severity L97.829 Non-pressure chronic ulcer of other part of left lower leg with unspecified severity L97.901 Non-pressure chronic ulcer of unspecified part of unspecified lower leg limited to breakdown of skin L97.902 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with fat layer exposed L97.903 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with necrosis of muscle L97.904 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with necrosis of bone L97.905 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with muscle involvement without evidence of necrosis L97.906 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with bone involvement without evidence of necrosis L97.908 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with other specified severity L97.909 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with unspecified severity L97.911 Non-pressure chronic ulcer of unspecified part of right lower leg limited to breakdown of skin L97.912 Non-pressure chronic ulcer of unspecified part of right lower leg with fat layer exposed L97.913 Non-pressure chronic ulcer of unspecified part of right lower leg with necrosis of muscle L97.914 Non-pressure chronic ulcer of unspecified part of right lower leg with necrosis of bone L97.915 Non-pressure chronic ulcer of unspecified part of right lower leg with muscle involvement without evidence of necrosis L97.916 Non-pressure chronic ulcer of unspecified part of right lower leg with bone involvement without evidence of necrosis L97.918 Non-pressure chronic ulcer of unspecified part of right lower leg with other specified severity

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L97.919 Non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity L97.921 Non-pressure chronic ulcer of unspecified part of left lower leg limited to breakdown of skin L97.922 Non-pressure chronic ulcer of unspecified part of left lower leg with fat layer exposed L97.923 Non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of muscle L97.924 Non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of bone L97.925 Non-pressure chronic ulcer of unspecified part of left lower leg with muscle involvement without evidence of necrosis L97.926 Non-pressure chronic ulcer of unspecified part of left lower leg with bone involvement without evidence of necrosis L97.928 Non-pressure chronic ulcer of unspecified part of left lower leg with other specified severity L97.929 Non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity M27.2 Inflammatory conditions of jaws M27.8 Other specified diseases of jaws M72.6 Necrotizing fasciitis M86.30 Chronic multifocal osteomyelitis, unspecified site M86.311 Chronic multifocal osteomyelitis, right shoulder M86.312 Chronic multifocal osteomyelitis, left shoulder M86.319 Chronic multifocal osteomyelitis, unspecified shoulder M86.321 Chronic multifocal osteomyelitis, right humerus M86.322 Chronic multifocal osteomyelitis, left humerus M86.329 Chronic multifocal osteomyelitis, unspecified humerus M86.331 Chronic multifocal osteomyelitis, right radius and ulna M86.332 Chronic multifocal osteomyelitis, left radius and ulna M86.339 Chronic multifocal osteomyelitis, unspecified radius and ulna M86.341 Chronic multifocal osteomyelitis, right hand M86.342 Chronic multifocal osteomyelitis, left hand M86.349 Chronic multifocal osteomyelitis, unspecified hand M86.351 Chronic multifocal osteomyelitis, right femur M86.352 Chronic multifocal osteomyelitis, left femur M86.359 Chronic multifocal osteomyelitis, unspecified femur M86.361 Chronic multifocal osteomyelitis, right tibia and fibula M86.362 Chronic multifocal osteomyelitis, left tibia and fibula M86.369 Chronic multifocal osteomyelitis, unspecified tibia and fibula M86.371 Chronic multifocal osteomyelitis, right ankle and foot M86.372 Chronic multifocal osteomyelitis, left ankle and foot M86.379 Chronic multifocal osteomyelitis, unspecified ankle and foot M86.38 Chronic multifocal osteomyelitis, other site M86.39 Chronic multifocal osteomyelitis, multiple sites M86.40 Chronic osteomyelitis with draining sinus, unspecified site M86.411 Chronic osteomyelitis with draining sinus, right shoulder M86.412 Chronic osteomyelitis with draining sinus, left shoulder M86.419 Chronic osteomyelitis with draining sinus, unspecified shoulder M86.421 Chronic osteomyelitis with draining sinus, right humerus M86.422 Chronic osteomyelitis with draining sinus, left humerus M86.429 Chronic osteomyelitis with draining sinus, unspecified humerus M86.431 Chronic osteomyelitis with draining sinus, right radius and ulna M86.432 Chronic osteomyelitis with draining sinus, left radius and ulna

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M86.439 Chronic osteomyelitis with draining sinus, unspecified radius and ulna M86.441 Chronic osteomyelitis with draining sinus, right hand M86.442 Chronic osteomyelitis with draining sinus, left hand M86.449 Chronic osteomyelitis with draining sinus, unspecified hand M86.451 Chronic osteomyelitis with draining sinus, right femur M86.452 Chronic osteomyelitis with draining sinus, left femur M86.459 Chronic osteomyelitis with draining sinus, unspecified femur M86.461 Chronic osteomyelitis with draining sinus, right tibia and fibula M86.462 Chronic osteomyelitis with draining sinus, left tibia and fibula M86.469 Chronic osteomyelitis with draining sinus, unspecified tibia and fibula M86.471 Chronic osteomyelitis with draining sinus, right ankle and foot M86.472 Chronic osteomyelitis with draining sinus, left ankle and foot M86.479 Chronic osteomyelitis with draining sinus, unspecified ankle and foot M86.48 Chronic osteomyelitis with draining sinus, other site M86.49 Chronic osteomyelitis with draining sinus, multiple sites M86.50 Other chronic hematogenous osteomyelitis, unspecified site M86.511 Other chronic hematogenous osteomyelitis, right shoulder M86.512 Other chronic hematogenous osteomyelitis, left shoulder M86.519 Other chronic hematogenous osteomyelitis, unspecified shoulder M86.521 Other chronic hematogenous osteomyelitis, right humerus M86.522 Other chronic hematogenous osteomyelitis, left humerus M86.529 Other chronic hematogenous osteomyelitis, unspecified humerus M86.531 Other chronic hematogenous osteomyelitis, right radius and ulna M86.532 Other chronic hematogenous osteomyelitis, left radius and ulna M86.539 Other chronic hematogenous osteomyelitis, unspecified radius and ulna M86.541 Other chronic hematogenous osteomyelitis, right hand M86.542 Other chronic hematogenous osteomyelitis, left hand M86.549 Other chronic hematogenous osteomyelitis, unspecified hand M86.551 Other chronic hematogenous osteomyelitis, right femur M86.552 Other chronic hematogenous osteomyelitis, left femur M86.559 Other chronic hematogenous osteomyelitis, unspecified femur M86.561 Other chronic hematogenous osteomyelitis, right tibia and fibula M86.562 Other chronic hematogenous osteomyelitis, left tibia and fibula M86.569 Other chronic hematogenous osteomyelitis, unspecified tibia and fibula M86.571 Other chronic hematogenous osteomyelitis, right ankle and foot M86.572 Other chronic hematogenous osteomyelitis, left ankle and foot M86.579 Other chronic hematogenous osteomyelitis, unspecified ankle and foot M86.58 Other chronic hematogenous osteomyelitis, other site M86.59 Other chronic hematogenous osteomyelitis, multiple sites M86.60 Other chronic osteomyelitis, unspecified site M86.611 Other chronic osteomyelitis, right shoulder M86.612 Other chronic osteomyelitis, left shoulder M86.619 Other chronic osteomyelitis, unspecified shoulder M86.621 Other chronic osteomyelitis, right humerus M86.622 Other chronic osteomyelitis, left humerus M86.629 Other chronic osteomyelitis, unspecified humerus M86.631 Other chronic osteomyelitis, right radius and ulna M86.632 Other chronic osteomyelitis, left radius and ulna M86.639 Other chronic osteomyelitis, unspecified radius and ulna M86.641 Other chronic osteomyelitis, right hand M86.642 Other chronic osteomyelitis, left hand

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M86.649 Other chronic osteomyelitis, unspecified hand M86.651 Other chronic osteomyelitis, right thigh M86.652 Other chronic osteomyelitis, left thigh M86.659 Other chronic osteomyelitis, unspecified thigh M86.661 Other chronic osteomyelitis, right tibia and fibula M86.662 Other chronic osteomyelitis, left tibia and fibula M86.669 Other chronic osteomyelitis, unspecified tibia and fibula M86.671 Other chronic osteomyelitis, right ankle and foot M86.672 Other chronic osteomyelitis, left ankle and foot M86.679 Other chronic osteomyelitis, unspecified ankle and foot M86.68 Other chronic osteomyelitis, other site M86.69 Other chronic osteomyelitis, multiple sites M86.8x0 Other osteomyelitis, multiple sites M86.8x1 Other osteomyelitis, shoulder M86.8x2 Other osteomyelitis, upper arm M86.8x3 Other osteomyelitis, forearm M86.8x4 Other osteomyelitis, hand M86.8x5 Other osteomyelitis, thigh M86.8x6 Other osteomyelitis, lower leg M86.8x7 Other osteomyelitis, ankle and foot M86.8x8 Other osteomyelitis, other site M86.8x9 Other osteomyelitis, unspecified sites N30.40 Irradiation cystitis without hematuria N30.41 Irradiation cystitis with hematuria S07.0xxA Crushing injury of face, initial encounter S07.0xxS Crushing injury of face, sequela S07.1xxA Crushing injury of skull, initial encounter S07.1xxD Crushing injury of skull, subsequent encounter S07.1xxS Crushing injury of skull, sequela S07.8xxA Crushing injury of other parts of head, initial encounter S07.8xxD Crushing injury of other parts of head, subsequent encounter S07.8xxS Crushing injury of other parts of head, sequela S07.9xxA Crushing injury of head, part unspecified, initial encounter S07.9xxD Crushing injury of head, part unspecified, subsequent encounter S07.9xxS Crushing injury of head, part unspecified, sequela S17.0xxA Crushing injury of larynx and trachea, initial encounter S17.0xxD Crushing injury of larynx and trachea, subsequent encounter S17.0xxS Crushing injury of larynx and trachea, sequela S17.8xxA Crushing injury of other specified parts of neck, initial encounter S17.8xxD Crushing injury of other specified parts of neck, subsequent encounter S17.8xxS Crushing injury of other specified parts of neck, sequela S17.9xxA Crushing injury of neck, part unspecified, initial encounter S17.9xxD Crushing injury of neck, part unspecified, subsequent encounter S17.9xxS Crushing injury of neck, part unspecified, sequela S28.0xxA Crushed chest, initial encounter S28.0xxA Crushed chest, initial encounter S28.0xxA Crushed chest, initial encounter S28.0xxD Crushed chest, subsequent encounter S28.0xxS Crushed chest, sequela S38.001A Crushing injury of unspecified external genital organs, male, initial encounter S38.001D Crushing injury of unspecified external genital organs, male, subsequent encounter

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S38.001S Crushing injury of unspecified external genital organs, male, sequela S38.002A Crushing injury of unspecified external genital organs, female, initial encounter S38.002D Crushing injury of unspecified external genital organs, female, subsequent encounter S38.002S Crushing injury of unspecified external genital organs, female, sequela S38.01xA Crushing injury of penis, initial encounter S38.01xD Crushing injury of penis, subsequent encounter S38.01xS Crushing injury of penis, sequela S38.02xA Crushing injury of scrotum and testis, initial encounter S38.02xD Crushing injury of scrotum and testis, subsequent encounter S38.02xS Crushing injury of scrotum and testis, sequela S38.03 Crushing injury of vulva S38.03xA Crushing injury of vulva, initial encounter S38.03xD Crushing injury of vulva, subsequent encounter S38.03xS Crushing injury of vulva, sequela S38.1xxA Crushing injury of abdomen, lower back, and pelvis, initial encounter S38.1xxA Crushing injury of abdomen, lower back, and pelvis, initial encounter S38.1xxD Crushing injury of abdomen, lower back, and pelvis, subsequent encounter S38.1xxS Crushing injury of abdomen, lower back, and pelvis, sequela S47.1xxA Crushing injury of right shoulder and upper arm, initial encounter S47.1xxA Crushing injury of right shoulder and upper arm, initial encounter S47.1xxA Crushing injury of right shoulder and upper arm, initial encounter S47.1xxA Crushing injury of right shoulder and upper arm, initial encounter S47.1xxA Crushing injury of right shoulder and upper arm, initial encounter S47.1xxA Crushing injury of right shoulder and upper arm, initial encounter S47.1xxD Crushing injury of right shoulder and upper arm, subsequent encounter S47.1xxS Crushing injury of right shoulder and upper arm, sequela S47.2xxA Crushing injury of left shoulder and upper arm, initial encounter S47.2xxA Crushing injury of left shoulder and upper arm, initial encounter S47.2xxA Crushing injury of left shoulder and upper arm, initial encounter S47.2xxA Crushing injury of left shoulder and upper arm, initial encounter S47.2xxA Crushing injury of left shoulder and upper arm, initial encounter S47.2xxA Crushing injury of left shoulder and upper arm, initial encounter S47.2xxD Crushing injury of left shoulder and upper arm, subsequent encounter S47.2xxS Crushing injury of left shoulder and upper arm, sequela S47.9xxA Crushing injury of shoulder and upper arm, unspecified arm, initial encounter S47.9xxA Crushing injury of shoulder and upper arm, unspecified arm, initial encounter S47.9xxA Crushing injury of shoulder and upper arm, unspecified arm, initial encounter S47.9xxA Crushing injury of shoulder and upper arm, unspecified arm, initial encounter S47.9xxA Crushing injury of shoulder and upper arm, unspecified arm, initial encounter S47.9xxA Crushing injury of shoulder and upper arm, unspecified arm, initial encounter S47.9xxA Crushing injury of shoulder and upper arm, unspecified arm, initial encounter S47.9xxD Crushing injury of shoulder and upper arm, unspecified arm, subsequent encounter S47.9xxS Crushing injury of shoulder and upper arm, unspecified arm, sequela S57.00xA Crushing injury of unspecified elbow, initial encounter S57.00xD Crushing injury of unspecified elbow, subsequent encounter S57.00xS Crushing injury of unspecified elbow, sequela S57.01xA Crushing injury of right elbow, initial encounter S57.01xD Crushing injury of right elbow, subsequent encounter S57.01xS Crushing injury of right elbow, sequela S57.02xA Crushing injury of left elbow, initial encounter S57.02xD Crushing injury of left elbow, subsequent encounter

17

S57.02xS Crushing injury of left elbow, sequela S57.80xA Crushing injury of unspecified forearm, initial encounter S57.80xD Crushing injury of unspecified forearm, subsequent encounter S57.80xS Crushing injury of unspecified forearm, sequela S57.81xA Crushing injury of right forearm, initial encounter S57.81xD Crushing injury of right forearm, subsequent encounter S57.81xS Crushing injury of right forearm, sequela S57.82xA Crushing injury of left forearm, initial encounter S57.82xD Crushing injury of left forearm, subsequent encounter S57.82xS Crushing injury of left forearm, sequela S67.00xA Crushing injury of unspecified thumb, initial encounter S67.00xD Crushing injury of unspecified thumb, subsequent encounter S67.00xS Crushing injury of unspecified thumb, sequela S67.01xA Crushing injury of right thumb, initial encounter S67.01xD Crushing injury of right thumb, subsequent encounter S67.01xS Crushing injury of right thumb, sequela S67.02xA Crushing injury of left thumb, initial encounter S67.02xD Crushing injury of left thumb, subsequent encounter S67.02xS Crushing injury of left thumb, sequela S67.10xA Crushing injury of unspecified finger(s), initial encounter S67.10xD Crushing injury of unspecified finger(s), subsequent encounter S67.10xS Crushing injury of unspecified finger(s), sequela S67.190A Crushing injury of right index finger, initial encounter S67.190D Crushing injury of right index finger, subsequent encounter S67.190S Crushing injury of right index finger, sequela S67.191A Crushing injury of left index finger, initial encounter S67.191D Crushing injury of left index finger, subsequent encounter S67.191S Crushing injury of left index finger, sequela S67.192A Crushing injury of right middle finger, initial encounter S67.192D Crushing injury of right middle finger, subsequent encounter S67.192S Crushing injury of right middle finger, sequela S67.193A Crushing injury of left middle finger, initial encounter S67.193D Crushing injury of left middle finger, subsequent encounter S67.193S Crushing injury of left middle finger, sequela S67.194A Crushing injury of right ring finger, initial encounter S67.194D Crushing injury of right ring finger, subsequent encounter S67.194S Crushing injury of right ring finger, sequela S67.195A Crushing injury of left ring finger, initial encounter S67.195D Crushing injury of left ring finger, subsequent encounter S67.195S Crushing injury of left ring finger, sequela S67.196A Crushing injury of right little finger, initial encounter S67.196D Crushing injury of right little finger, subsequent encounter S67.196S Crushing injury of right little finger, sequela S67.197A Crushing injury of left little finger, initial encounter S67.197D Crushing injury of left little finger, subsequent encounter S67.197S Crushing injury of left little finger, sequela S67.198A Crushing injury of other finger, initial encounter S67.198D Crushing injury of other finger, subsequent encounter S67.198S Crushing injury of other finger, sequela S67.20xA Crushing injury of unspecified hand, initial encounter S67.20xD Crushing injury of unspecified hand, subsequent encounter

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S67.20xS Crushing injury of unspecified hand, sequela S67.21xA Crushing injury of right hand, initial encounter S67.21xD Crushing injury of right hand, subsequent encounter S67.21xS Crushing injury of right hand, sequela S67.22xA Crushing injury of left hand, initial encounter S67.22xD Crushing injury of left hand, subsequent encounter S67.22xS Crushing injury of left hand, sequela S67.30xA Crushing injury of unspecified wrist, initial encounter S67.30xD Crushing injury of unspecified wrist, subsequent encounter S67.30xS Crushing injury of unspecified wrist, sequela S67.31xA Crushing injury of right wrist, initial encounter S67.31xD Crushing injury of right wrist, subsequent encounter S67.31xS Crushing injury of right wrist, sequela S67.32xA Crushing injury of left wrist, initial encounter S67.32xD Crushing injury of left wrist, subsequent encounter S67.32xS Crushing injury of left wrist, sequela S67.40xA Crushing injury of unspecified wrist and hand, initial encounter S67.40xD Crushing injury of unspecified wrist and hand, subsequent encounter S67.40xS Crushing injury of unspecified wrist and hand, sequela S67.41xA Crushing injury of right wrist and hand, initial encounter S67.41xD Crushing injury of right wrist and hand, subsequent encounter S67.41xS Crushing injury of right wrist and hand, sequela S67.42xA Crushing injury of left wrist and hand, initial encounter S67.42xD Crushing injury of left wrist and hand, subsequent encounter S67.42xS Crushing injury of left wrist and hand, sequela S67.90xA Crushing injury of unspecified part(s) of unspecified wrist, hand and fingers, initial encounter S67.90xD Crushing injury of unspecified part(s) of unspecified wrist, hand and fingers, subsequent encounter S67.90xS Crushing injury of unspecified part(s) of unspecified wrist, hand and fingers, sequela S67.91xA Crushing injury of unspecified part(s) of right wrist, hand and fingers, initial encounter S67.91xD Crushing injury of unspecified part(s) of right wrist, hand and fingers, subsequent encounter S67.91xS Crushing injury of unspecified part(s) of right wrist, hand and fingers, sequela S67.92xA Crushing injury of unspecified part(s) of left wrist, hand and fingers, initial encounter S67.92xD Crushing injury of unspecified part(s) of left wrist, hand and fingers, subsequent encounter S67.92xS Crushing injury of unspecified part(s) of left wrist, hand and fingers, sequela S77.00xA Crushing injury of unspecified hip, initial encounter S77.00xD Crushing injury of unspecified hip, subsequent encounter S77.00xS Crushing injury of unspecified hip, sequela S77.01xA Crushing injury of right hip, initial encounter S77.01xD Crushing injury of right hip, subsequent encounter S77.01xS Crushing injury of right hip, sequela S77.02xA Crushing injury of left hip, initial encounter S77.02xD Crushing injury of left hip, subsequent encounter S77.02xS Crushing injury of left hip, sequela S77.10xA Crushing injury of unspecified thigh, initial encounter S77.10xD Crushing injury of unspecified thigh, subsequent encounter S77.10xS Crushing injury of unspecified thigh, sequela S77.11xA Crushing injury of right thigh, initial encounter

19

S77.11xD Crushing injury of right thigh, subsequent encounter S77.11xS Crushing injury of right thigh, sequela S77.12xA Crushing injury of left thigh, initial encounter S77.12xD Crushing injury of left thigh, subsequent encounter S77.12xS Crushing injury of left thigh, sequela S77.20xA Crushing injury of unspecified hip with thigh, initial encounter S77.20xA Crushing injury of unspecified hip with thigh, initial encounter S77.20xA Crushing injury of unspecified hip with thigh, initial encounter S77.20xA Crushing injury of unspecified hip with thigh, initial encounter S77.20xD Crushing injury of unspecified hip with thigh, subsequent encounter S77.20xS Crushing injury of unspecified hip with thigh, sequela S77.21xA Crushing injury of right hip with thigh, initial encounter S77.21xD Crushing injury of right hip with thigh, subsequent encounter S77.21xS Crushing injury of right hip with thigh, sequela S77.22xA Crushing injury of left hip with thigh, initial encounter S77.22xD Crushing injury of left hip with thigh, subsequent encounter S77.22xS Crushing injury of left hip with thigh, sequela S87.00xA Crushing injury of unspecified knee, initial encounter S87.00xD Crushing injury of unspecified knee, subsequent encounter S87.00xS Crushing injury of unspecified knee, sequela S87.01xA Crushing injury of right knee, initial encounter S87.01xD Crushing injury of right knee, subsequent encounter S87.01xS Crushing injury of right knee, sequela S87.02xA Crushing injury of left knee, initial encounter S87.02xD Crushing injury of left knee, subsequent encounter S87.02xS Crushing injury of left knee, sequela S87.80xA Crushing injury of unspecified lower leg, initial encounter S87.80xD Crushing injury of unspecified lower leg, subsequent encounter S87.80xS Crushing injury of unspecified lower leg, sequela S87.81xA Crushing injury of right lower leg, initial encounter S87.81xD Crushing injury of right lower leg, subsequent encounter S87.81xS Crushing injury of right lower leg, sequela S87.82xA Crushing injury of left lower leg, initial encounter S87.82xD Crushing injury of left lower leg, subsequent encounter S87.82xS Crushing injury of left lower leg, sequela S97.00xA Crushing injury of unspecified ankle, initial encounter S97.00xD Crushing injury of unspecified ankle, subsequent encounter S97.00xS Crushing injury of unspecified ankle, sequela S97.01xA Crushing injury of right ankle, initial encounter S97.01xD Crushing injury of right ankle, subsequent encounter S97.01xS Crushing injury of right ankle, sequela S97.02xA Crushing injury of left ankle, initial encounter S97.02xD Crushing injury of left ankle, subsequent encounter S97.02xS Crushing injury of left ankle, sequela S97.80xA Crushing injury of unspecified foot, initial encounter S97.80xD Crushing injury of unspecified foot, subsequent encounter S97.80xS Crushing injury of unspecified foot, sequela S97.81xA Crushing injury of right foot, initial encounter S97.81xD Crushing injury of right foot, subsequent encounter S97.81xS Crushing injury of right foot, sequela S97.82xA Crushing injury of left foot, initial encounter

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S97.82xD Crushing injury of left foot, subsequent encounter S97.82xS Crushing injury of left foot, sequela T58.01xA Toxic effect of carbon monoxide from motor vehicle exhaust, accidental (unintentional), initial encounter T58.01xD Toxic effect of carbon monoxide from motor vehicle exhaust, accidental (unintentional), subsequent encounter T58.01xS Toxic effect of carbon monoxide from motor vehicle exhaust, accidental (unintentional), sequela T58.02xA Toxic effect of carbon monoxide from motor vehicle exhaust, intentional self-harm, initial encounter T58.02xD Toxic effect of carbon monoxide from motor vehicle exhaust, intentional self-harm, subsequent encounter T58.02xS Toxic effect of carbon monoxide from motor vehicle exhaust, intentional self-harm, sequela T58.03xA Toxic effect of carbon monoxide from motor vehicle exhaust, assault, initial encounter T58.03xD Toxic effect of carbon monoxide from motor vehicle exhaust, assault, subsequent encounter T58.03xS Toxic effect of carbon monoxide from motor vehicle exhaust, assault, sequela T58.04xA Toxic effect of carbon monoxide from motor vehicle exhaust, undetermined, initial encounter T58.04xD Toxic effect of carbon monoxide from motor vehicle exhaust, undetermined, subsequent encounter T58.04xS Toxic effect of carbon monoxide from motor vehicle exhaust, undetermined, sequela T58.11xA Toxic effect of carbon monoxide from utility gas, accidental (unintentional), initial encounter T58.11xD Toxic effect of carbon monoxide from utility gas, accidental (unintentional), subsequent encounter T58.11xS Toxic effect of carbon monoxide from utility gas, accidental (unintentional), sequela T58.12xA Toxic effect of carbon monoxide from utility gas, intentional self-harm, initial encounter T58.12xD Toxic effect of carbon monoxide from utility gas, intentional self-harm, subsequent encounter T58.12xS Toxic effect of carbon monoxide from utility gas, intentional self-harm, sequela T58.13xA Toxic effect of carbon monoxide from utility gas, assault, initial encounter T58.13xD Toxic effect of carbon monoxide from utility gas, assault, subsequent encounter T58.13xS Toxic effect of carbon monoxide from utility gas, assault, sequela T58.14xA Toxic effect of carbon monoxide from utility gas, undetermined, initial encounter T58.14xD Toxic effect of carbon monoxide from utility gas, undetermined, subsequent encounter T58.14xS Toxic effect of carbon monoxide from utility gas, undetermined, sequela T58.2x1A Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, accidental (unintentional), initial encounter T58.2x1D Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, accidental (unintentional), subsequent encounter T58.2x1S Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, accidental (unintentional), sequela T58.2x2A Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, intentional self-harm, initial encounter T58.2x2D Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, intentional self-harm, subsequent encounter T58.2x2S Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, intentional self-harm, sequela

21

T58.2x3A Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, assault, initial encounter T58.2x3D Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, assault, subsequent encounter T58.2x3S Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, assault, sequela T58.2x4A Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, undetermined, initial encounter T58.2x4D Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, undetermined, subsequent encounter T58.2x4S Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, undetermined, sequela T58.8x1A Toxic effect of carbon monoxide from other source, accidental (unintentional), initial encounter T58.8x1D Toxic effect of carbon monoxide from other source, accidental (unintentional), subsequent encounter T58.8x1S Toxic effect of carbon monoxide from other source, accidental (unintentional), sequela T58.8x2A Toxic effect of carbon monoxide from other source, intentional self-harm, initial encounter T58.8x2D Toxic effect of carbon monoxide from other source, intentional self-harm, subsequent encounter T58.8x2S Toxic effect of carbon monoxide from other source, intentional self-harm, sequela T58.8x3 Toxic effect of carbon monoxide from other source, assault T58.8x3A Toxic effect of carbon monoxide from other source, assault, initial encounter T58.8x3D Toxic effect of carbon monoxide from other source, assault, subsequent encounter T58.8x3S Toxic effect of carbon monoxide from other source, assault, sequela T58.8x4A Toxic effect of carbon monoxide from other source, undetermined, initial encounter T58.8x4D Toxic effect of carbon monoxide from other source, undetermined, subsequent encounter T58.8x4S Toxic effect of carbon monoxide from other source, undetermined, sequela T58.91xA Toxic effect of carbon monoxide from unspecified source, accidental (unintentional), initial encounter T58.91xD Toxic effect of carbon monoxide from unspecified source, accidental (unintentional), subsequent encounter T58.91xS Toxic effect of carbon monoxide from unspecified source, accidental (unintentional), sequela T58.92xA Toxic effect of carbon monoxide from unspecified source, intentional self-harm, initial encounter T58.92xD Toxic effect of carbon monoxide from unspecified source, intentional self-harm, subsequent encounter T58.92xS Toxic effect of carbon monoxide from unspecified source, intentional self-harm, sequela T58.93xA Toxic effect of carbon monoxide from unspecified source, assault, initial encounter T58.93xD Toxic effect of carbon monoxide from unspecified source, assault, subsequent encounter T58.93xS Toxic effect of carbon monoxide from unspecified source, assault, sequela T58.94xA Toxic effect of carbon monoxide from unspecified source, undetermined, initial encounter T58.94xD Toxic effect of carbon monoxide from unspecified source, undetermined, subsequent encounter T58.94xS Toxic effect of carbon monoxide from unspecified source, undetermined, sequela T65.0x1A Toxic effect of cyanides, accidental (unintentional), initial encounter T65.0x1D Toxic effect of cyanides, accidental (unintentional), subsequent encounter

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T65.0x1S Toxic effect of cyanides, accidental (unintentional), sequela T65.0x2A Toxic effect of cyanides, intentional self-harm, initial encounter T65.0x2D Toxic effect of cyanides, intentional self-harm, subsequent encounter T65.0x2S Toxic effect of cyanides, intentional self-harm, sequela T65.0x3A Toxic effect of cyanides, assault, initial encounter T65.0x3D Toxic effect of cyanides, assault, subsequent encounter T65.0x3S Toxic effect of cyanides, assault, sequela T65.0x4A Toxic effect of cyanides, undetermined, initial encounter T65.0x4D Toxic effect of cyanides, undetermined, subsequent encounter T65.0x4S Toxic effect of cyanides, undetermined, sequela T66.xxxA Radiation sickness, unspecified, initial encounter T70.20xA Unspecified effects of high altitude, initial encounter T70.20xD Unspecified effects of high altitude, subsequent encounter T70.20xS Unspecified effects of high altitude, sequela T70.29xA Other effects of high altitude, initial encounter T70.29xD Other effects of high altitude, subsequent encounter T70.29xS Other effects of high altitude, sequela T70.3xxA Caisson disease [decompression sickness], initial encounter T70.3xxD Caisson disease [decompression sickness], subsequent encounter T70.3xxS Caisson disease [decompression sickness], sequela T79.0xxA Air embolism (traumatic), initial encounter T79.0xxD Air embolism (traumatic), subsequent encounter T79.0xxS Air embolism (traumatic), sequela T79.8xxA Other early complications of trauma, initial encounter T79.8xxD Other early complications of trauma, subsequent encounter T79.8xxS Other early complications of trauma, sequela T79.9xxA Unspecified early complication of trauma, initial encounter T79.9xxD Unspecified early complication of trauma, subsequent encounter T79.9xxS Unspecified early complication of trauma, sequela T86.820 Skin graft (allograft) rejection T86.821 Skin graft (allograft) (autograft) failure T86.822 Skin graft (allograft) (autograft) infection T86.828 Other complications of skin graft (allograft) (autograft) T86.829 Unspecified complication of skin graft (allograft) (autograft) T87.0x1 Complications of reattached (part of) right upper extremity T87.0x2 Complications of reattached (part of) left upper extremity T87.0x9 Complications of reattached (part of) unspecified upper extremity T87.0x9 Complications of reattached (part of) unspecified upper extremity T87.0x9 Complications of reattached (part of) unspecified upper extremity T87.0x9 Complications of reattached (part of) unspecified upper extremity T87.0x9 Complications of reattached (part of) unspecified upper extremity T87.1x1 Complications of reattached (part of) right lower extremity T87.1x2 Complications of reattached (part of) left lower extremity T87.1x9 Complications of reattached (part of) unspecified lower extremity T87.1x9 Complications of reattached (part of) unspecified lower extremity T87.1x9 Complications of reattached (part of) unspecified lower extremity T87.1x9 Complications of reattached (part of) unspecified lower extremity T87.2 Complications of other reattached body part

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Description 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.

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.

Adverse Events HBOT is a generally safe therapy, with an estimated adverse side effect rate of 0.4%.4, Adverse events may occur either from pressure effects or the oxygen. The pressure effect (barotrauma) may affect any closed air-filled cavity such as ears, sinus, teeth, and lungs. Pain and/or swelling may occur at these sites as pressure increases during the procedure and decreases as the procedure is ending. Oxygen toxicity may affect the pulmonary, neurologic, or ophthalmologic systems. Pulmonary symptoms include a mild cough, substernal burning, and dyspnea. Neurologic effects include tunnel vision, tinnitus, nausea, and dizziness. Ophthalmologic effects include retinopathy in neonates, cataract formation, and transient myopic vision changes.

Note that this evidence review does not address topical oxygen therapy in the absence of pressurization.

Summary Description 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.

Summary of Evidence For individuals with wounds, burns or infections who receive topical hyperbaric oxygen therapy (HBOT), the evidence includes a systematic review, case series, and a randomized controlled trial (RCT). Relevant outcomes are overall survival (OS), symptoms, change in disease status, and functional outcomes. The systematic review identified 3 RCTs including patients with sacral pressure ulcers, ischial pressure ulcers, and refractory venous ulcers. All trials reported that healing improved significantly after HBOT than after standard of care. Pooling of results was not possible due to heterogeneity in patient populations and treatment regimens. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

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For individuals with chronic diabetic ulcers who receive systemic HBOT, the evidence includes RCTs and systematic reviews. Relevant outcomes are symptoms and change in disease status. Meta-analyses of RCTs found significantly higher diabetic ulcer healing rates with HBOT than with control conditions. Two of the 3 meta-analyses found that HBOT was associated with a significantly lower rate of major amputation. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with carbon monoxide poisoning who receive systemic HBOT, the evidence includes RCTs and a systematic review. Relevant outcomes are OS and symptoms. A meta-analysis in a Cochrane review of low-quality RCT data did not find HBOT to be associated with a significantly lower risk of neurologic deficits after carbon monoxide poisoning. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with radionecrosis, osteoradionecrosis, or treatment of irradiated jaw who receive systemic HBOT, the evidence includes RCTs and a systematic review. Relevant outcomes are symptoms and change in disease status. A meta-analysis in a Cochrane review of RCTs found evidence that HBOT improved radionecrosis and osteoradionecrosis outcomes and resulted in better outcomes before tooth extraction in an irradiated jaw. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with chronic refractory osteomyelitis who receive systemic HBOT, the evidence includes case series. Relevant outcomes are symptoms and change in disease status. The case series reported high rates of successful outcomes (no drainage, pain, tenderness, or cellulitis) in patients with chronic refractory osteomyelitis treated with HBOT. However, controlled studies are needed to determine conclusively the impact of HBOT on health outcomes compared with other interventions. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with acute thermal burns who receive systemic HBOT, the evidence includes a systematic review of 2 RCTs. Relevant outcomes are OS, symptoms, and change in disease status. Both RCTs were judged to have poor methodologic quality. Evidence from well-conducted controlled trials is needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with acute surgical and traumatic wounds who receive systemic HBOT, the evidence includes RCTs, controlled nonrandomized studies, and systematic reviews. Relevant outcomes are OS, symptoms, change in disease status, and functional outcomes. There was considerable heterogeneity across the 4 RCTs identified (eg, patient population, comparison group, treatment regimen, outcomes). This heterogeneity prevented pooling of trial findings and limits the ability to definitively conclude the impact of HBOT on health outcomes for patients with acute surgical and traumatic wounds. Additional evidence from high-quality RCTs is needed. A systematic review of controlled Chinese studies suggests HBOT may increase the survival rate of compromised skin grafts and flaps when initiated within 72 hours; however, risk of bias in the original Chinese publications cannot be evaluated. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with bisphosphonate-related osteonecrosis of the jaw who receive systemic HBOT, the evidence includes an RCT. Relevant outcomes are symptoms and change in disease status. The RCT was unblinded and reported initial benefits at 3-month follow-up; however, there were no significant benefits of HBOT for most health outcomes compared with standard care in the long-term (6 months to 2 years).The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with necrotizing soft tissue infections who receive systemic HBOT, the evidence includes systematic reviews. Relevant outcomes are OS, symptoms, and change in disease status. A Cochrane review did not identify any RCTs. Another systematic review of retrospective cohort studies with methodological limitations did not find consistent benefit of adjunctive HBOT use. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

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For individuals with acute coronary syndrome who receive systemic HBOT, the evidence includes RCTs and a systematic review. Relevant outcomes are OS, symptoms, change in disease status, and functional outcomes. A Cochrane review identified 6 RCTs. There were 2 pooled analyses, 1 found significantly lower rates of death with HBOT and the other reported inconsistent results in left ventricular function. Additional RCT data are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with acute ischemic stroke with or without motor dysfunction associated with stroke who receive systemic HBOT, the evidence includes RCTs and a systematic review. Relevant outcomes are OS, symptoms, change in disease status, and functional outcomes. Cochrane reviewers could only pool data for a single outcome for acute ischemic stroke (mortality at 3 to 6 months), and for that outcome, there was no significant difference between active and sham HBOT treatments. An RCT found that HBOT combined with DAPT may enhance neurological recovery, and support daily living activities in elderly acute cerebral infarction patients; larger, multicenter studies with standardized HBOT protocols and extended follow-up are needed to confirm these findings. For motor dysfunction, an RCT, which used a crossover design, found better outcomes with HBOT at 2 months than with delayed treatment. However, the trial had a number of methodologic limitations (eg, lack of patient blinding, heterogeneous population, high dropout rate) that make it difficult to evaluate the efficacy of HBOT. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with motor dysfunction associated with stroke who receive systemic HBOT, the evidence includes an RCT. Relevant outcomes are symptoms and functional outcomes. The RCT, which used a crossover design, found better outcomes with HBOT at 2 months than with delayed treatment. However, the trial had a number of methodologic limitations (eg, lack of patient blinding, heterogeneous population, high dropout rate) that make it difficult to evaluate the efficacy of HBOT. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with Bell palsy who receive systemic HBOT, the evidence includes a systematic review. Relevant outcomes are symptoms, change in disease status, and functional outcomes. A Cochrane review did not identify any RCTs meeting selection criteria; the single RCT found did not have a blinded outcome assessment. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with traumatic brain injury who receive systemic HBOT, the evidence includes RCTs and systematic reviews. Relevant outcomes are OS, symptoms, change in disease status, and functional outcomes. RCTs were heterogeneous regarding intervention protocols, patient populations, and outcomes reported. Systematic reviews conducted pooled analyses only on a minority of the published RCTs, and these findings were inconsistent. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with inflammatory bowel disease who receive systemic HBOT, the evidence includes RCTs, observational studies, and a systematic reviews. Relevant outcomes are symptoms, change in disease status and functional outcomes. RCTs have reported mixed findings in patients with ulcerative colitis, with one study terminated early due to futility. A systematic review including the RCT and observational studies found a high rate of bias in the literature due to attrition and reporting bias. Another systematic review found that HBOT appears to be a safe and effective adjunctive therapy for UC, with potential benefits for CD requiring further investigation. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with idiopathic sudden sensorineural hearing loss who receive systemic HBOT, the evidence includes systematic reviews. Relevant outcomes are symptoms, change in disease status, and functional outcomes. A Cochrane review of RCTs had mixed findings from studies that included individuals with tinnitus. Some outcomes (ie, improvement in hearing of all frequencies, >25% return of hearing) were better with HBOT than with a control intervention, but more than 50% return of hearing did

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not differ significantly between groups. There was important variability in the patients enrolled in the studies. A subsequent systematic review had similarly limited conclusions due to the inclusion of non- randomized studies. A third review found a higher proportion of patients with hearing recovery with HBOT compared to medical treatment alone, but the analysis was limited to 2 RCTs with methodological limitations. One RCT published subsequent to the systematic reviews found a positive effect of HBOT plus steroid combination therapy on measures of auditory function compared to either HBOT or steroids alone, but other outcomes were not reported and the study had numerous relevance, design, and conduct limitations. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with delayed-onset muscle soreness who receive systemic HBOT, the evidence includes RCTs and a systematic review. Relevant outcomes are symptoms and functional outcomes. A Cochrane review of RCTs found worse short-term pain outcomes with HBOT than with control and no difference in longer-term pain or other outcomes (eg, swelling). The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with autism spectrum disorder who receive systemic HBOT, the evidence includes an RCT and a systematic review. Relevant outcomes are symptoms and functional outcomes. A Cochrane review identified a single RCT on HBOT for autism spectrum disorder and this trial did not find significantly better parental-assessed or clinician-assessed outcomes with HBOT compared with sham. A subsequent controlled trial reached the same conclusion. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with cerebral palsy who receive systemic HBOT, the evidence includes 2 RCTs and an observational study. Relevant outcomes are symptoms and functional outcomes. One RCT was stopped early due to futility, and the other did not find significantly better outcomes with HBOT than with a sham intervention. The observational study focused on sleep disorders in children with cerebral palsy and reported improvements with the HBOT treatment. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with vascular dementia who receive systemic HBOT, the evidence includes an RCT and a systematic review. Relevant outcomes are symptoms and functional outcomes. The Cochrane review identified only a single RCT with methodologic limitations. Well-conducted controlled trials are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with radiotherapy adverse events who receive systemic HBOT, the evidence includes RCTs, nonrandomized comparator trials, case series, and systematic reviews. Relevant outcomes are symptoms and functional outcomes. Two systematic reviews included few RCTs and provide limited evidence on the effect of HBOT. Two RCTs had inconsistent findings. One reported no short-term benefit with HBOT, but some benefits 12 months after radiotherapy; the other did not find a significant benefit of HBOT at 12-month follow-up. Another RCT assessed HBOT for radiation-induced cystitis and found significant benefit by some measures but not others. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with idiopathic femoral neck necrosis who receive systemic HBOT, the evidence includes an RCT. Relevant outcomes are symptoms, change in disease status, and functional outcomes. The RCT, which had a small sample, only reported short-term (ie, 6-week) outcomes. Larger well- conducted RCTs reporting longer-term outcomes are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

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For individuals with a migraine who receive systemic HBOT, the evidence includes RCTs and a systematic review. Relevant outcomes are symptoms, change in disease status, and functional outcomes. The Cochrane review conducted a pooled analysis including 3 of the 11 trials. Meta-analysis of these 3 RCTs found significantly greater relief of migraine symptoms with HBOT than with a comparator intervention within 45 minutes of treatment. Longer-term data are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with herpes zoster who receive systemic HBOT, the evidence includes an RCT. Relevant outcomes are symptoms and change in disease status. The RCT was unblinded and only reported short-term (ie, 6-week) outcomes. Additional well-conducted RCTs with longer follow-up are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with fibromyalgia who receive systemic HBOT, the evidence includes RCTs. Relevant outcomes are symptoms, change in disease status, and functional outcomes. Only 2 RCTs were identified, and both reported positive effects of HBOT on tender points and pain. However, the trials had relatively small samples and methodologic limitations (eg, quasi-randomization, no or uncertain sham control for a condition with subjective outcomes susceptible to a placebo effect). Moreover, the HBOT protocols varied. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with multiple sclerosis who receive systemic HBOT, the evidence includes RCTs and a systematic review. Relevant outcomes are symptoms and functional outcomes. A Cochrane review of RCTs did not find a significant difference in Expanded Disability Status Scale scores when patients with multiple sclerosis were treated with HBOT versus a comparator intervention. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with cancer and are undergoing chemotherapy who receive systemic HBOT, the evidence includes an RCT and a systematic review. Relevant outcomes are OS and change in disease status. While the systematic review reported improvements in tumor control in patients with head and neck cancer who received HBOT, the adverse events accompanying the treatment (eg, radiation tissue injury, seizures) were significant. The single RCT did not find a significant difference in survival for cancer patients who received HBOT before chemotherapy compared with usual care. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 4/2026 Annual policy review. Policy updated with literature review through December 8, 2025; references added. Policy statements unchanged. 2/2025 Annual policy review. Policy updated with literature review through June 7, 2024. References added. Clinical input added. Based on results of structured request for clinical input, treatment of necrotizing soft tissue infections, idiopathic sudden sensorineural hearing loss, and central retinal artery occlusion added to medically necessary statement. Coding clarified. Effective 2/1/2025. 11/2023 Annual policy review. Policy revised to include coverage for the treatment of compromised skin grafts and flaps to medically necessary statement. Clarified coding information. Effective 11/1/2023. 6/2022 Clarified prior authorization information. Prior Authorization is not required effective 6/1/2022. Clarified coding information. 4/2021 Literature review through 4/2021 on idiopathic sudden sensorineural hearing loss. References added. Policy statement unchanged. 3/2020 Annual policy review. Description, summary and references updated. Policy statements unchanged. 1/2020 Coding information clarified. 6/2019 Coding information clarified.

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4/2019 Coding information clarified. 3/2019 Annual policy review. Description, summary and references updated. Policy statements unchanged. 2/2018 Annual policy review. New references added. 2/2017 Annual policy review. New references added. 5/2016 Prior authorization table clarified. 1/2016 Annual policy review. New investigational indications described. Effective 1/1/2016. 1/2015 Clarified coding information. 10/2014 Annual policy review. Investigational statements clarified. Title changed from “Hyperbaric Oxygen Pressurization (HBO)” to “Hyperbaric Oxygen Therapy.” Effective 10/1/2014. 6/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015. Coding information clarified. 2/2014 Annual policy review. New investigational indications described. Effective 2/1/2014.
Coding information clarified. 3/2013 Annual policy review. Change to policy statement. Effective 3/1/2013. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements.
4/2011 Reviewed - Medical Policy Group - Cardiology and Pulmonology. No changes to policy statements. 12/2010 Reviewed - Medical Policy Group - Plastic Surgery and Dermatology. No changes to policy statements. 12/2009 Reviewed - Medical Policy Group - Plastic Surgery and Dermatology. No changes to policy statements. 4/2009 Annual policy review. No changes to policy statements. 12/2008 Reviewed - Medical Policy Group - Plastic Surgery and Dermatology. No changes to policy statements. 5/2008 Annual policy review. Changes to policy statements. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

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