Hyperbaric Oxygen (HBO) Therapy Form

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Hyperbaric Oxygen (HBO) Therapy - Medical Policy
Updated Revision Effective: 10/1/2025 Policy Number:

UM125POL

Approval Date:

Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Hyperbaric oxygen (HBO) is a treatment in which an individual intermittently breathes nearly 100% oxygen while in a chamber pressurized to at least 1.4 ATA (atmospheres absolute). Medical grade oxygen, as specified by the United States Pharmacopoeia, the Compressed Gas Association, and the National Fire Protection Association, is defined as being greater than 99.0% by volume. HBO may be used as either primary or adjunctive treatment.

HBO therapy facilitates improvement primarily by counteracting hypoxia. Secondary effects include promotion of wound healing through neovascularization by both local (e.g., steepened oxygen gradient, increased growth factors, progenitor stem cell recruitment) and systemic (e.g., bone marrow progenitor stem cell mobilization) effects, attenuation of ischemic inflammatory cascade, anti-microbial bactericidal effects, and decreased edema.

The most common adverse effects associated with the use of HBO include middle ear barotrauma, sinus pain, otitis media, claustrophobia, progressive nearsightedness, which tends to resolve after treatment, and cataract progression. A retrospective study identified the overall incidence of middle ear barotrauma to be 43.2%. There was no statistically significant increased risk of middle ear barotrauma with different treatment pressures (e.g., 2 ATA, 2.5 ATA, 2.8 ATA). Oxygen tolerance limits have been set (based on results from healthy volunteers) to avoid oxygen toxicity to the pulmonary and neurologic systems. A retrospective study of 931 individuals with over 23,000 treatments evaluated seizure risk due to oxygen toxicity at pressures greater than 2.0 ATA. The overall seizure incidence in this study was 5 in 10,000 treatments.

 Line of Business

Commercial:

• Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:

• Refer to criteria under the Policy section in this medical policy.
• There are no MassHealth guidelines for Hyperbaric Oxygen (HBO) Therapy.

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Medicare:

• Health New England follows National Coverage Determination (NCD) Hyperbaric Oxygen Therapy (20.29). for the first 30 treatments. https://www.cms.gov/medicare-coverage-database/search.aspx.

• For additional treatment, refer to criteria under Policy section in this medical policy. Policy

I. Criteria for Approval of HBO therapy, initial 30 outpatient visits, for Commercial and Medicaid:

• Health New England may consider Hyperbaric Oxygen Therapy MEDICALLY NECESSARY for ANY of the following indications:

A. Acute peripheral artery insufficiency due to arterial embolism or thrombosis by imaging or physical examination when ALL of the following are met:

1. Hyperbaric oxygen therapy planned as adjunct or bridge to surgery; AND

2. Acute event ≤ 24 hours.

   B. Acute traumatic peripheral ischemia by imaging or physical examination when ALL of the following are met:

3. Hyperbaric oxygen therapy planned as adjunct or bridge to surgery; AND
4. Acute event ≤ 24 hours.
5. C. Compromised skin graft or flap when ALL of the following are met:
6. Graft or flap initially viable; AND
7. Graft or flap compromised due to hypoxia or decreased perfusion; AND

8. Treated mechanical compromise to graft or flap or no mechanical compromise. .

   D. Crush injury with open fracture when ANY of the following are met:

9. Open fracture classification Gustilo IIIB or IIIC, when: a. Blood flow at site adequate by testing or physical examination. OR

10. Open fracture classification Gustilo I or II or IIIA, when: a. Impaired health status but not completely decompensated (A score between 3.5 and 7 would be considered “impaired" on the Wellness Score; those who score less than 3.5 would be considered “decompensated”); AND b. Blood flow at site adequate by testing or physical examination.

    E. Delayed osteoradionecrosis by imaging when ALL of the following are met:

11. Radiation treatment was completed 6 months prior to symptom onset; AND
12. Surgery planned or not feasible; AND

13. No infection or infection is actively being treated.

    F. Delayed soft tissue radionecrosis (e.g., radiation cystitis, radiation enteritis, radiation proctitis, radiation laryngeal necrosis) when ALL of the following are met:

14. Radiation treatment was completed 6 months prior to symptom onset; AND
15. Surgery planned or not feasible; AND
16. No infection or infection is actively being treated.

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G. Diabetic foot ulcer or lower extremity wound when ALL of the following are met:

1. Diabetes mellitus (DM) type I or II; AND
2. Wagner Classification ≥ grade 3; ANDA

3. (a) Acutely infected or necrotic wound and surgical wound debridement performed when: a. Adequate circulation in the affected extremity by physical examination or testing or imaging; AND b. Revascularization performed or not indicated or not feasible; AND c. Glycemic levels controlled or being treated; AND d. Postoperative wound care planned; AND e. No infection or infection being actively treated.

   ORA

   (b) Continued non-healing foot ulcer or wound after ≥ 30 consecutive days of treatment and non-surgical debridement in a type I or II Diabetic and Wagner Classification ≥ grade 3, when: a. Adequate circulation in the affected extremity by physical examination or testing or imaging; AND b. Revascularization performed or not indicated or not feasible; AND c. Glycemic levels controlled or being treated; AND d. Moist wound environment with dressings; AND e. Non-weight-bearing or pressure reduction or not feasible; AND f. No infection or infection being actively treated.

   H. Gas gangrene (clostridial myositis and myonecrosis), when ALL of the following are met:

4. Surgery and Anti-infective treatment are planned.

   I. Intracranial abscess by imaging, when the following are met:

5. Multiple abscesses or abscess in deep or dominant location; OR
6. Immunocompromised patient; OR
7. Poor surgical candidate or surgery not feasible; OR

8. Continued or worsening symptoms or findings after surgery and anti-infective treatment.

   J. Malignant external otitis by imaging or biopsy, when the following are met:

9. Hyperbaric oxygen therapy planned as adjunct to anti-infective treatment; OR

10. Continued symptoms or findings after anti-infective treatment.

    K. Musculoskeletal compartment syndrome when the following criteria is met:

11. Impending phase when: a. Healthy individual and compartment pressure > normal and ≤ 45 mmHg; OR b. Impaired health status and compartment pressure > normal and ≤ 35 mmHg; OR c. Decompensation or shock and compartment pressure > normal and ≤ 25 mmHg; OR

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d. Skeletal muscle compartment pressure measurement is not feasible but 3 more of the following are present:

1) Disproportionate pain 2) Skin sensation decreased 3) Weakness 4) Pain with passive stretch 5) Taut muscle compartment by palpation.

OR

2. Established phase and fasciotomy delayed OR Post fasciotomy complications or risk factors.

   L. Progressive necrotizing infection, when ALL of the following criteria are met:

3. Surgery planned; AND

4. Anti-infective treatment planned.

   M. Refractory osteomyelitis, when the following criteria is met:

5. Osteomyelitis of the sternum OR Osteomyelitis of the vertebrae OR Osteomyelitis of the cranium.

   OR

6. Stage 3 or 4 osteomyelitis; AND
7. Class B systemic or local complications present; AND
8. No abscess or abscess drained or drainage not feasible; AND

9. Surgical debridement or hardware removal performed or not feasible.

   N. Second- or third-degree thermal burn, when ALL of the following criteria are met:

10. Burn ≥ 20% total body surface area (BSA) OR hands or ears or face or feet or perineum affected; AND
11. Surgery planned; AND
12. Anti-infective therapy planned or not indicated; AND
13. Burn wound care; AND

14. Fluid replacement and management planned.

    O. Severe anemia requiring blood transfusion, when ALL of the following criteria are met:

15. Blood transfusion is not possible.

    P. Sudden sensorineural hearing loss, when ALL of the following criteria are met:

16. Sudden unilateral hearing loss of unknown etiology; AND
17. Moderate or moderately severe or severe or profound hearing loss; AND
18. Hearing loss ≥ 30 db from baseline; AND
19. Hearing loss over a 3-day period; AND
20. Hearing loss ≥ 3 sequential frequencies; AND
21. Systemic or intratympanic corticosteroid therapy planned and symptom onset ≤ 2 weeks OR continued hearing loss after corticosteroid treatment and symptom onset ≤ 4 weeks.

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Q. Suspected air or gas embolism, when the following criteria are met:

1. Arterial gas embolism; AND
2. ANY of the following: a. Loss of consciousness; OR b. Altered mental status or other neurological symptoms; OR c. Arrhythmia; OR d. Extremity weakness or paralysis or paresthesias; OR e. Visual or hearing changes; OR f. Extreme fatigue; OR g. Nausea or vomiting; OR h. Bloody sputum; OR i. Chest pain; OR j. Shortness of breath; AND

3. Other etiologies of symptoms or findings excluded.

   OR

4. Venous gas embolism; AND
5. ANY of the following: a. Cardiac arrest; OR b. Cough; OR c. Shortness of breath; OR d. Pulmonary edema by imaging or physical examination; OR e. Chest pain; AND

6. Other etiologies of symptoms or findings excluded.

   R. Suspected carbon monoxide poisoning, when the following criteria are met:

7. Symptoms consistent with carbon monoxide exposure; AND

8. ANY of the following: a. Headache; OR b. Nausea or vomiting; OR c. Altered mental status or other neurological symptoms, OR d. Chest pain or other cardiac manifestations; OR e. Shortness of breath; OR f. Loss of consciousness; OR g. Myalgias.

   OR

9. Suspected cyanide poisoning with history of fire exposure and criteria above from 1 to 3
   are met with cyanide poisoning antidote planned.

                 OR

10. Asymptomatic and carbon monoxide exposure by history; AND
11. ANY of the following: a. Age ≥ 36; OR b. Pregnant; OR c. Carboxyhemoglobin ≥ 25%; OR d. Metabolic acidosis (pH < 7.2); OR e. ≥ 24 hours of carbon monoxide exposure; OR f. Cardiopulmonary disease by history; OR g. Multiple comorbidities by history.

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S. Suspected central retinal artery occlusion, when the following criteria are met:

1. Sudden painless vision loss by history; AND
2. Symptom onset ≤ 24 hours; AND

3. Other etiologies excluded.

   T. Suspected decompression sickness by history, when the following criteria are met:

4. Any of the following: a. Joint pain; OR b. Hyperesthesias or paresthesias; OR c. Tinnitus or hearing loss; OR d. Skin eruptions or mottling; OR e. Malaise or extreme fatigue; OR f. Chest pain or shortness of breath; OR g. Vertigo or tremors or ataxia; OR h. Altered mental status.

   U. Actinomycosis, when the following criteria are met:

5. Only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment.

   II. Criteria for Approval of HBO therapy, initial 30 outpatient visits, for Medicare:

   • Health New England follows National Coverage Determination (NCD) Hyperbaric Oxygen Therapy (20.29). NCD - Hyperbaric Oxygen Therapy (20.29) (cms.gov)

   III. HNE will consider approving 30 additional outpatient HBO therapy visits when the initial services have occurred and a status report is received with clear documentation of care plan including ALL of the following:

6. The member’s response to the HBO received; AND
7. All other types of treatment the member is receiving; AND

8. The physician’s projection for length of HBO therapy.

   IV. Requests for more than additional 30 visits will be determined on a case of case basis.

   V. Continued HBO treatments are considered NOT MEDICALLY NECESSARY if there have not been measurable signs of healing within any 30 days period of treatment.

   VI. HBO therapy is considered EXPERIMENTAL and INVESTIGATIONAL for the following indications.

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1. Acute Carbon tetrachloride poisoning
2. Hepatic necrosis
3. Acute coronary syndrome
4. Hepatitis
5. Acute or chronic cerebral vascular insufficiency
6. Herpes zoster
7. Acute osteomyelitis
8. Hydrogen sulfide poisoning
9. Acute surgical and traumatic wounds
10. Idiopathic femoral neck necrosis
11. Acute thermal and chemical pulmonary damage (smoke inhalation with
12. In vitro fertilization
13. Aerobic septicemia
14. Inflammatory bowel disease (ulcerative colitis, Crohn’s disease
15. AIDS/HIV
16. Intra-abdominal abscess
17. Alzheimer’s Disease
18. Intracranial abscess
19. Amyotrophic lateral sclerosis (ALS)
20. Lepromatous leprosy
21. Anaerobic septicemia and infection other than Clostridia
22. Lupus vasculitis
23. Anorectal conditions (fistula, fissure)
24. Meningitis
25. Arthritic diseases
26. Migraine
27. Asthma
28. Multiple sclerosis
29. Autism Spectrum disorders
30. Myocardial infarction
31. Avascular necrosis
32. Necrotizing soft tissue infections
33. Bell’s Palsy
34. Nonvascular causes of chronic brain syndrome (Pick’s disease, Alzheimer’s disease, and Korsakoff’s disease)
35. Bisphosphonate-related osteonecrosis of the jaw
36. Organ storage
37. Bone grafts
38. Organ transplantation
39. Brain Injury
40. Parkinson’s disease
41. Brown spider bites
42. Post-concussion syndrome
43. Calciphylaxis (calcific uremic arteriolopathy)
44. Pseudomembranous colitis
45. Cancer
46. Pulmonary emphysema

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24. Cardiogenic shock
25. Pyoderma gangrenosum
26. Cerebral edema
27. Radiation induced neck and head injury
28. Cerebral Palsy
29. Radiation myelitis
30. Chronic arm lymphedema
31. Refractory mycoses
32. Chronic peripheral vascular insufficiency
33. Retinal artery insufficiency
34. Chronic wounds other than diabetic, if meets medical necessity criteria
35. Retinopathy
36. Cognitive impairment, vascular dementia
37. Senility
38. Compromised skin flaps or grafts
39. Sickle cell crisis and/or hematuria/ anemia
40. Cutaneous, decubitus, and stasis ulcers
41. Skin burns (thermal)
42. Decubitus ulcers/Venous stasis ulcers
43. Spinal cord injury
44. Delayed onset muscle soreness
45. Stroke
46. Depression, mental illness
47. Systemic aerobic infection
48. Early treatment for radiation effects
49. Tetanus
50. Extreme Blood loss anemia
51. Tinnitus
52. Fibromyalgia
53. Topical application of oxygen (E & I)
54. Fracture healing
55. Tumor sensitization for cancer treatments
56. HBO not covered prophylactically for patients undergoing radiation of the bladder
57. Wagner Grade 2 or lower diabetic foot ulcer
58. Heart disease
59. Interstitial cystitis

60. Chemotherapy induced hemorrhagic cystitis

    Policy Guidelines and Definitions

    Definitions:

    The 0- to 10-point Wellness Score

    • Considers activities of daily living, ambulation status, comorbidities, smoking, and use of steroids, as well as evidence of neurological deficits, and is used to assess health status.
    • Points are assigned depending on functional status with a maximum of 10 points given.

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• A score between 3.5 and 7 would be considered “impaired" on the Wellness Score; those who score less than 3.5 would be considered “decompensated” (Moon, Hyperbaric oxygen therapy indications. Undersea and Hyperbaric Oxygen Medical Society Committee Report. 14th edition. 2019).

• Wagner Grading System:

  Grade 0
  No open ulceration, but with possible existence of bone deformation of hyperkeratosis Grade 1
  Superficial ulcer without penetration of deep layers
  Grade 2
  Deeper ulcer, reaching tendon, bone or joint capsule
  Grade 3
  Deeper tissues are involved and there is abscess, osteomyelitis or tendonitis
  Grade 4
  There is gangrene of some part of the toe(s) and/or forefoot Grade 5
  Gangrene involves the whole foot or enough of the foot that no local procedures are possible and BKA is indicated.

  Coding Guidance

  Code
  Description
  PA CPT code

  99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session
  (Reported for physician attendance of each session of hyperbaric oxygen therapy.) No HCPCS code

  A4575 Topical hyperbaric oxygen chamber, disposable (experimental/investigational) No G0277 Hyperbaric oxygen under pressure, full body chamber, per 30 min interval. Yes

  CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

  Note: CPT/HCPCS codes are included for informational purposes and may not be all-inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

  References

  Moon, Hyperbaric oxygen therapy indications. Undersea and Hyperbaric Oxygen Medical Society Committee Report. 14th edition. 2019.

  Kirby, Mo Med 2019, 116: 184-7; Moon, Hyperbaric oxygen therapy indications. Undersea and Hyperbaric Oxygen Medical Society Committee Report. 14th edition. 2019.

  Sen and Sen, Med Gas Res 2021, 11: 30-3.

  Bennett and Mitchell, Curr Opin Anaesthesiol 2019, 32: 792-8.

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Tejada et al., Curr Pharm Des 2019, 25: 1682-93.

Francis and Baynosa, Adv Wound Care (New Rochelle) 2017, 6: 23-32.

Lam et al., Adv Skin Wound Care 2017, 30: 181-90.

Morton and Phillips, J Am Acad Dermatol 2016, 74: 589-605.

Heyboer et al., Undersea Hyperb Med 2014, 41: 393-7.

Heyboer et al., Undersea Hyperb Med 2014, 41: 379-85.

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 9/2003 Initial policy effective date 11/2023 No significant criteria changes. References updated. 1/2024 Added Line of Business section 12/2024 Criteria developed for each individual indication for Commercial and Medicaid line of business. 5/2025 Removed “No untreated pneumothorax” from requirements for all indications.
Removed “Nutritional evaluation performed” from requirements of Diabetic Foot ulcer and lower extremity wound. Added clarification to Delayed soft tissue radionecrosis. Added to indications considered experimental investigational: • Chemotherapy induced hemorrhagic cystitis • Interstitial cystitis Updated coding table: Added A4575 as experimental/investigational.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health

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professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at the time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.