Point32 Hyperbaric Oxygen Therapy Form

Hyperbaric Oxygen Therapy (HBO)

Hyperbaric Oxygen Therapy (HBO) is used to treat a variety of conditions including carbon monoxide poisoning, tissue injury due to radiation exposure, trauma, chronic wounds, surgery, or infection. During the therapy the patient breathes in and is exposed to pure oxygen at a pressure typically 2 to 3 times greater than the atmospheric pressure. The elevated concentration of blood plasma and by non-poisoned hemoglobin elevating oxygen delivery to the tissues It is intended to either accelerate or cause healing that would not ordinarily occur.

Depending on the condition being treated, HBO can work through increasing systemic blood oxygen levels, increasing ambient pressure while reducing blood nitrogen levels (countering the primary cause and mechanism of decompression sickness), increasing the oxygen levels in wounded tissue, and/or exposing anaerobic bacteria to a pure oxygen environment.

Clinical Guideline Coverage Criteria

The Plan considers non-emergent hyperbaric oxygen therapy (HBO) as reasonable and medically necessary when documentation confirms ONE of the following conditions:

1. Severe or profound anemia with exceptional blood loss: only when blood transfusion is impossible or must be delayed.
2. Preparation and preservation of hypoxia- or decreased-perfusion-compromised skin grafts and flaps, supported by photograph (with ruler for scale), identification flap/graft type, graft surgeon identification, surgical exploration results, and transcutaneous oxygen tension testing results indicating hypoxia (TcPO2 less than 40mmHg on room air), when conventional treatment failure is indicated by ONE of the following:
   • Etiology of compromise cannot be identified.
   • Etiology of compromise cannot be corrected surgically.
   • Compromise persists despite correction of all identified etiologies.
3. Adjunctive treatment with conventional therapy for ONE of the following WHEN unresponsive to conventional therapy alone:
   • Osteo- or soft tissue radionecrosis (e.g., radiation enteritis, cystitis, proctitis) when chronic and refractory to conventional medical and/or surgical management that includes debridement or resection of nonviable tissue along with antibiotic therapy.
     • If treatment is for osteoradionecrosis of the jaw, there is evidence of bony resorption or overt fracture in a previously irradiated mandible.
   • Chronic refractory osteomyelitis unresponsive to (or in a case contraindicating) at least surgical debridement and a six-week course of parenteral antibiotics.
   • Progressive necrotizing infections (necrotizing fasciitis, Meleney’s ulcer), with conventional treatment having included inpatient antibiotics, surgical debridement, and, when indicated, skin grafts.
   • Actinomycosis refractory to antibiotics and surgical treatment.
   • Sudden sensorineural hearing loss (SSNHL) according to standard definition (hearing decline of at least 30 decibels in at least three sequential frequencies in no more than three days) as an addition to corticosteroid treatment when initiation of HBO treatment is within fourteen days of onset.
4. Adjunctive treatment of diabetic ulcerations/wounds of the lower extremities when ALL of the following are confirmed:
   • Ulcerations have a severity of at least Wagner grade III.
   • Ulcerations have not healed appreciably after thirty days of standard wound therapy, including ALL the following:
     • Assessment and correction of vascular condition in affected limb(s).
     • Nutritional adjustment.
     • Glucose control improvement.
     • Debridement.
     • Maintenance of granulation tissue cleanliness and moisture with dressings.
     • Appropriate off-loading.

Treatment of any infection

Coverage of hyperbaric oxygen therapy for non-emergent conditions requires:

• Prior authorization
• All conditions being treated with adjunctive HBO, including treatment of compromised grafts and diabetic ulcerations, must be evaluated, and documented at least every 15 sessions and at least every 30 days of treatment

For members with compromised skin grafts or diabetic foot wounds, the following criteria must be met:

• The treatment can be used as adjunctive therapy only when there has been no measurable improvement in the Member’s condition
• A treatment plan has been submitted to HPHC for review which includes the proposed number of treatments as well as the goal of the therapy

For members with osteoradionecrosis, The Plan will consider coverage of hyperbaric oxygen therapy as an adjunctive treatment. A letter of medical necessity must be submitted

Note:

• The Plan will not cover hyperbaric oxygen therapy as a prophylactic measure, including prior to the extraction of teeth or other oral surgery procedures
• The Plan considers adjunctive HBO as not medically necessary when following any 30-day period in which measurable signs of healing have not been demonstrated

Guidelines:

The Wagner Diabetic Foot Ulcer Grade Classification System is as follows:

Hyperbaric Oxygen Treatment (HBO)

0 No open lesion
1 Superficial ulcer without penetration to deeper layers
2 Ulcer penetrates to tendon, bone, or joint
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
4 Wet or dry gangrene in the toes or forefoot
5 Gangrene involves the whole foot or such a percentage that no local procedures are possible and amputation (at least below the knee level) is indicated

Limitations

The Plan considers topical oxygen therapy as experimental/investigational regardless of place of setting. In addition, The Plan considers full-body hyperbaric oxygen therapy (HBO) as not medically necessary for all other indications including but not limited to:

1. Acute cerebral edema
2. Acute osteomyelitis
3. Hepatic necrosis
4. Aerobic septicemia
5. Cutaneous, decubitus, and stasis ulcer
6. Chronic peripheral vascular insufficiency
7. Acute or chronic cerebral vascular insufficiency
8. Arthritic diseases
9. Nonvascular factors in chronic brain syndromes (such as dementia, Pick's disease, Alzheimer's disease, Korsakoff's disease)
10. Multiple sclerosis
11. Pulmonary emphysema
12. Myocardial ischemia or infarction
13. Acute coronary syndrome
14. Cardiogenic shock
15. Sickle cell anemia
16. Tetanus
17. Systemic aerobic infection
18. Suspected central retinal artery occlusion
19. Acute chemical and thermal pulmonary damage
20. Preconditioning for coronary artery bypass graft surgery
21. Organ storage and transplantation
22. Intra-abdominal abscess
23. Inflammatory bowel disease (Crohn's Disease, ulcerative colitis)
24. Brown recluse spider bites
25. Wagner Grade 2 or lower diabetic foot ulcers
26. Cerebral Palsy
27. Autism Spectrum Disorder

Codes