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Date Printed: December 17, 2017: 10:10 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-99180-01

Original Effective Date: 01/01/01

Reviewed: 06/26/14

Revised: 10/01/16

Subject: Hyperbaric Oxygen Therapy (HBO2)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Hyperbaric oxygen therapy (HBO2) is a technique for delivering higher pressures of oxygen to the tissues. The air pressure inside a hyperbaric oxygen chamber is approximately two and a half times greater than the normal pressure in the atmosphere. Two methods of administration are available. In systemic or large chamber hyperbaric oxygen, the patient is entirely enclosed in a pressure chamber and breathes oxygen at a pressure greater than 1 atmosphere (the pressure of O2 at sea level). Thus, this technique relies on the systemic circulation to deliver highly oxygenated blood to the target site, typically a wound. In addition, systemic hyperbaric oxygen therapy can be used to treat systemic illness such as air or gas embolism, carbon monoxide poisoning, clostridial gas gangrene, etc. 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.

Topical hyperbaric oxygen therapy is a technique of delivering 100% oxygen directly to an open, moist wound at a pressure slightly higher than atmospheric pressure. It is believed that the high concentrations of oxygen diffuse directly into the wound to increase the local cellular oxygen tension, which in turn promotes wound healing. Topical hyperbaric oxygen 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.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request to expedite the medical review process.

1. Click the link Hyperbaric Oxygen Therapy (HBO2) - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

Hyperbaric oxygen therapy meets the definition of medical necessity when administered in a total body chamber and performed for the treatment of the following diagnoses or surgical procedures:

1. Actinomycosis – when administered in addition to conservative therapy when the disease is refractory to antibiotics and surgical treatment;

2. Arterial insufficiency, acute (including acute retinal artery occlusion);

3. Carbon monoxide intoxication, acute;

4. Chronic refractory osteomyelitis – when unresponsive to conservative medical and surgical management;

5. Crush injuries; compartment syndrome (does not include crushing head injuries) – when loss of function, limb, or life is threatened;

6. Cyanide poisoning – following administration of antidote;

7. Decompression sickness;

8. Gas or air embolism, acute;

9. Gas gangrene;

10. Idiopathic sudden sensorineural hearing loss

11. Necrotizing soft tissue infections (subcutaneous tissue, muscle, fascia)

− Fournier's gangrene

− Necrotizing fasciitis

− Polymicrobial progressive necrotizing infections.

12. Preparation and preservation of compromised skin grafts and flaps, excluding artificial skin grafts; (NOTE: Not for primary management of wounds.)

13. Radiation tissue injury (soft tissues and bone necrosis) – as an adjunct to conservative treatment;

14. Traumatic peripheral ischemia, acute – when loss of function, limb, or life is threatened;

15. Selected problem wounds (as indicated by transcutaneous evaluation of tissue oxygen tension) with documented tissue hypoxia with significant improvement on 100% oxygen at sea level or in the hyperbaric chamber

a. Amputation site breakdowns;

b. Diabetic wounds (i.e., wounds of the lower extremities due to diabetes) – when all of the following criteria are met:

− Type I or Type II diabetes with lower extremity wound due to diabetes;

− Wound is classified as Wagner grade 3 or higher;

− Sufficient course of standard wound therapy has failed (30 consecutive days without measurable signs of healing) – must be used in addition to standard wound care and re-evaluation after 30 days shows continued improvement; (NOTE: diabetic wound care includes assessment of member’s vascular status and correction of any vascular problems, optimization of nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, maintenance of a clean moist bed of granulation tissue with appropriate moist dressings, appropriate off-loading, and necessary treatment to resolve any infection present.)

c. Non-healing traumatic ulcerations;

d. Infected progressive ulcers (with documentation of culture and failure of other forms of therapy.)

16. Severe blood loss anemia when: blood transfusion is either impossible or must be delayed because suitable blood is not available or religion prohibits transfusions;

17. Smoke inhalation (carbon monoxide and cyanide poisoning);

18. Thermal burns (as an adjunct to comprehensive burn care program) (i.e., deep second or third degree);

19. Prophylactically prior to any type of oral surgery or dental procedure, to prevent osteoradionecrosis in patients having had previous radiation treatment. (NOTE: HBO therapy may be eligible for coverage only when the oral surgery or dental procedure is covered under the medical benefit.)

Additional diagnoses related to the conditions identified above may be eligible for coverage based on medical review to determine medical necessity. Documentation (e.g., physician history & physical, visit notes, laboratory studies) should describe "failed" therapy and show evidence of delayed wound healing, compromised circulation, significant culture reports (if applicable).

Conditions that frequently require additional treatments include: radiation necrosis, problem wounds, and osteomyelitis. Documentation should include evidence of progress and should support continued need for treatment.

Hyperbaric oxygen therapy is contraindicated in pregnancy except when specifically indicated for the treatment of carbon monoxide poisoning.

The application of hyperbaric oxygen therapy for indications other than those listed above does not meet the definition of medical necessity. Systemic hyperbaric oxygen therapy (HBO) is an established treatment option for a specific subgroup of conditions. There is a lack of clinical data published in the peer-reviewed literature in the form of randomized controlled trials to support effects on health outcomes for other indications.

Hyperbaric oxygen therapy in the absence of a physician is non-covered. The physician must be personally in attendance in the HBO area and accessible for monitoring the patient during the treatment session should problems or complications occur. This is a professional activity that cannot be delegated in that it requires independent medical judgment by the physician.

Topical hyperbaric oxygen therapy is a technique of delivering 100% oxygen directly to an open, moist wound using a device consisting of an appliance that encloses the wound area. This method of HBO therapy does not constitute hyperbaric oxygen therapy. Application of topical oxygen, for the treatment of open wounds, by methods such as, but not limited to, topical hyperbaric oxygen chambers (i.e., Topox, Oxyhealer, Oxychamber, Oxycure) is considered experimental or investigational, as there is limited scientific evidence to permit conclusions concerning the effect of this technology on health outcomes.

Ozone Therapy, the administration of oxygen by any method, intended to selectively inhibit the growth of cancerous cells, is considered experimental or investigational as there is insufficient published clinical studies to support effects on health outcomes.

BILLING/CODING INFORMATION:

The following codes may be used to describe hyperbaric oxygen therapy (HBO):

CPT Coding:

99183

Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session

HCPCS Coding:

A4575

Topical hyperbaric oxygen chamber, disposable (non-covered)

G0277

Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

A42.0 – A42.7
A42.81 – A42.89 A42.9

Actinomycosis

A48.0

Gas gangrene

D50.0
D62

Anemia secondary to blood loss

E08.52

Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene

E09.51 – E09.59

Drug or chemical induced diabetes mellitus with circulatory complications

E09.620 – E09.628

Drug or chemical induced diabetes mellitus with skin complications

E10.51 – E10.59

Type 1 diabetes mellitus with circulatory complications

E10.620 – E10.628

Type 1 diabetes mellitus with diabetic dermatitis

E11.51 – E11.59

Type 2 diabetes mellitus with circulatory complications

E13.620 – E13.628

Other specified diabetes mellitus with skin complications

H90.A21, H90.A22
H90.3
H90.41
H90.42
H90.5

Sensorineural hearing loss

I73.9

Peripheral vascular disease, unspecified

I74.2

Embolism and thrombosis of arteries of the upper extremities

I74.3

Embolism and thrombosis of arteries of the lower extremities

I74.5

Embolism and thrombosis if iliac artery

I96

Gangrene not elsewhere classified

J38.7

Other diseases of the larynx (necrosis)

K52.0

Gastroenteritis and colitis due to radiation

L08.89

Other specified local infections of the skin and subcutaneous tissue

L20.82
L20.84
L23.0

Contact dermatitis and other eczema

L59.0 – L59.9

Other disorders of skin and subcutaneous tissue related to radiation

L88

Pyoderma gangrenosum

L89.000 – L89.899
L89.90 – L89.95

Pressure ulcer

L97.101 – L97.929
L98.411 – L98.499

Non-pressure chronic ulcer

M27.2

Inflammatory conditions of jaws (radiation necrosis of jaw)

M27.8

Other specified diseases of jaws

M72.6

Necrotizing fasciitis

M86.311 – M86.319
M86.321 – M86.329
M86.331 – M86.339
M86.341 – M86.349
M86.351 – M86.359
M86.361 – M56.369
M86.371 – M86.379
M86.38
M86.39
M86.40
M86.411 – M86.419
M86.421 – M86.429
M86.431 – M86.439
M86.441 – M86.449
M86.451 – M86.459
M86.461 – M86.469
M86.471 – M86.479
M86.48
M86.49
M86.50
M86.511 – M86.519
M86.521 – M86.529
M86.531 – M86.539
M86.541 – M86.549
M86.551 – M86.559
M86.561 – M86.562
M86.569
M86.571 – M86.579
M86.58
M86.59
M86.60
M86.611 – M86.619,
M86.621 – M86.629,
M86.631 – M86.639,
M86.641 – M86.649,
M86.651 – M86.659,
M86.661 – M86.669,
M86.671 – M86.679,
M86.68
M86.69,
M86.8X0 – M86.8X9
M86.9

Chronic osteomyelitis

N30.40, N30.41

Irradiation cystitis

N49.3

Fournier gangrene

S07.0XXA

Crushing injury of face

S17.0XXA – S17.9XXS

Crusing injury of neck

S28.0XXA – S28.0XXS

Crushing injuy multiple sites of trunk

S28.1XXA – S28.229S

Traumatic amputation (partial) of part of thorax, except breast

S35.511A – S35.513S

Injury of iliac artery

S38.001A – S38.001S S38.002A – S38.002S S38.01XA – S38.03XS

Crushing injury of external genital organs

S38.1XXA – 38.1XXS S38.0XXA – S38.0XXS

Crushing injury of abdomen, lower back, and pelvis

S38.211A – S38.232S

Crushing injury and traumatic amputation of abdomen, lower back, pelvis and external genitals

S45.101A – S45.199S

Injury of brachial artery

S45.001A – S45.099S

Injury of axillary artery

S47.1XXA – S47.9XXS

Crushing injury of shoulder and upper arm

S48.011A – S48.929S

Traumatic amputation of shoulder and upper arm

S57.00XA – S57.02XS

Crushing injury of elbow

S57.80XA – S57.82XS

Crushing injury of forearm

S58.011A – S58.929S

Traumatic amputation of elbow and forearm

S67.00XA – S67.02XS

Crushing injury of thumb

S67.10XA – S67.10XS
S67.190A – S67.190S
S67.191A – S67.191S
S67.191A – S67.191S
S67.192A – S67.192S
S67.193A – S67.193S
S67.194A – S67.194S
S67.195A – S67.195S
S67.197A – S67.197S
S67.198A – S67.198S

Crushing injury of finger(s)

S67.20XA – S67.22XS

Crushing injury of hand(s)

S67.30XA – S67.32XS

Crushing injury of wrist

S67.40XA – S67.42XS

Crushing injury of wrist and hand

S67.90XA – S67.92XS

Crushing injury of unspecified part(s) of wrist, hand and fingers

S68.011A – S68.729S

Traumatic amputation of wrist, hand and fingers

S75.001A – S75.099S

Injury of femoral artery

S77.00XA – S77.02XS
S77.10XA – S77.10XS
S77.11XA – S77.11XS
S77.12XA – S77.12XS
S77.20XA – S77.20XS
S77.21XA – S77.21XS
S77.22XA – S77.22XS

Crushing injury of hip and thigh

S78.011A – S78.929S

Traumatic amputation of hip and thigh

S85.001A – S85.099S

Injury of blood vessels at lower leg level

S87.00XA – S87.82XS

Crushing injury of lower leg

S88.011A – S88.929S

Traumatic amputation of lower leg

S97.00XA – S97.02XS
S97.101A – S97.129S
S97.80XA – S97.82XS

Crushing injury of ankle, foot, toe

S98.011A – S98.929S

Traumatic amputation of ankle and foot

T20.00XA – T20.79XS
T21.00XA – T21.79XS
T22.00XA – T22.00XS
T22.011A – T22.799S
T23.001A – T23.799S
T24.001A – T24.799S
T25.011A – T25.799S
T26.00XA – T26.92XS
T27.0XXA – T27.7XXS
T28.0XXA – T28.3XXS
T28.40XA – T28.40XS
T28.411A – T28.419S
T28.49XA – T28.49XS
T28.5XXA – T28.8XXS
T28.90XA – T28.90XS
T28.911A – T28.919S
T28.99XA – T28.99XS
T30.0 – T30.4
T31.0
T31.10 – T31.99
T32.0
T32.10 – T32.99

Burns and corrosions

T57.3X1A – T57.3X1S T57.3X2A – T57.3X2S T57.3X3A – T57.3X3S T57.3X4A

Toxic effect of hydrocyanic acid gas

T58.01XA – T58.01XS
T58.02XA – T58.02XS
T58.03XA – T58.03XS
T58.04XA – T58.04XS
T58.11XA – T58.11XS
T58.12XA – T58.12XS
T58.13XA – T58.13XS
T58.14XA – T58.14XS
T58.2X1A – T58.2X2S
T58.2X3A – T58.2X3S
T58.2X4A – T58.2X4S
T58.8X1A – T58.8X1S
T58.8X2A – T58.8X2S
T58.8X3A – T58.8X3S
T58.8X4A – T58.8X4S
T58.91XA – T58.91XS
T58.92XA – T58.92XS
T58.93XA – T58.93XS
T58.94XA

Toxic effect of carbon monoxide

T59.811A – T59.811S

Toxic effect of smoke inhalation

T65.0X1A – T65.0X1S

Toxic effect of hydrocyanic acid and cyanides

T66.XXXA – T66.XXXS

Radiation sickness

T70.29XA – T70.29XS

Effects of high altitude

T70.3XXA – T70.3XXS

Caisson disease (decompression sickness)

T79.0XXA – T79.0XXS

Air embolism

T79.8XXA – T79.8XXS

Other early complications of trauma

T79.A0XA – T79A9XS

Compartment syndrome, unspecified

T80.0XXA – T80.0XXS

Air embolism (traumatic)

T86.820 – T86.829

Complications of skin graft (allograft) (autograft)

T78.0X1 – T87.0X9
T87.1X1 – T87.1X9
T87.2

Complications of reattached (part of) extremity or body part

T87.30 – T87.34
T87.40 – T87.44
T87.50 – T87.54
T87.81
T87.89
T87.9

Complications of amputation (stump)

Z94.5

Skin transplant status

REIMBURSEMENT INFORMATION:

Reimbursement for HBO (99183) is limited to thirty (30) treatments within a 12 month period. Services in excess of this limitation are subject to medical review of documentation in support of medical necessity. The following information may be required documentation to support medical necessity: physician initial assessment, physician history and physical, physician visit note, and laboratory studies.

LOINC Codes:

DOCUMENTATION TABLE

LOINC CODES

LOINC TIME FRAME MODIFIER CODE

LOINC TIME FRAME MODIFIER CODES NARRATIVE

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Laboratory studies

26436-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

NOTE: Each unit billed equals one treatment, regardless of the length of time spent in the HBO chamber.

EXAMPLE: 1 hour in the chamber equals one treatment; 2 hours in the chamber equals one treatment.

Continuation of HBO2 therapy

Medical records (e.g., attending physician initial assessment, visit notes) should demonstrate measurable signs of healing within any 30-day period of treatment, documenting the medical necessity for continuation of HBO2 therapy beyond the recommended limitations. Additionally, wound location, size, description of wound bed and drainage should be documented.

The following may indicate effective treatment outcomes from HBO2 therapy:

  1. Improvement or healing of wounds
  2. Improvement of tissue perfusion
  3. New epithelial tissue growth and granulation
  4. Tissue PO2 of at least 30 mmHg of oxygen is necessary for oxidative function to occur
  5. Mechanical reduction in the bubble size of air emboli improves decompression sickness and gas or air emboli
  6. Tissue PO2 of 40 or greater defines resolved hypoxia. At this point, the body is able to resume host functions of wound healing and anti-microbial defenses, eliminating the need for continued HBO therapy.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Hyperbaric Oxygen Therapy (20.29) located at cms.gov.

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Hyperbaric Oxygen Therapy (L29192) located at fcso.com.

DEFINITIONS:

Actinomycosis: an infectious disease characterized by inflammatory lesions of the lymph nodes draining the mouth, intraperitoneal abscesses, including liver abscess, or by lung abscess due to aspiration, in that order of frequency; slow, relatively painless enlargement of the nodes with reddening of the overlying skin.

Atmospheric pressure: the unit of pressure equal to exactly 101325 pascals, the pressure exerted by the earth’s atmosphere at sea level, approximately 760 mm Hg.

Compartment syndrome: an acute medical problem following injury, surgery or in most cases, repetitive and extensive muscle use, in which increased pressure (usually caused by inflammation) within a confined space (fascial compartment) in the body impairs blood supply that, in turn, may lead to nerve damage and muscle death. Common causes of compartment syndrome include tibial or forearm fractures, ischemic-reperfusion following injury, hemorrhage, vascular puncture, intravenous drug injection, casts, prolonged limb compression, crush injuries, and burns.

Empyema: the presence of purulent material (pus) in a bodily cavity.

Hyperbaric: characterized by greater than normal pressure or weight; applied to gases under greater than atmospheric pressure (as hyperbaric oxygen) or to a solution of greater specific gravity than another taken as a standard of reference.

Osteomyelitis: inflammation of the bone caused by a pyogenic organism; may remain localized or may spread through the bone to involved the marrow, cortex, cancellous tissue, and periosteum.

Ozone: a bluish explosive gas or blue liquid, which is an allotropic (existence of a substance in two or more forms) and more active form of oxygen.

Radiation necrosis: death of tissue caused by radiation.

RELATED GUIDELINES:

Oxygen, 09-E0400

OTHER:

The Undersea and Hyperbaric Medical Society’s 2008 Hyperbaric Oxygen Therapy Committee suggests utilization of HBO as described below:

Indication:

Treatment threshold levels:

Carbon monoxide poisoning/cyanide poisoning

5 treatments (sessions)

Gas gangrene

10 treatments (sessions)

Acute traumatic ischemia, crush injury

3 treatments (sessions) per day for 48 hours followed by 2 treatments per day over the second 48 hours and 1 treatment per day over the third period of 48 hours. (3 – 12 treatments (sessions))

Decompression sickness

10 treatments (sessions) – treatment times vary depending on length of time elapsed between symptoms and initiation of treatment and between residual symptoms after initial treatment. Usual time between treatments range from 1.5 to 14.0 hours. Repetitive treatments may be necessary, depending on patient’s response.

Idiopathic sudden sensorineural hearing loss

20 treatments (sessions)

Exceptional blood loss anemia

or class IV hemorrhage, HBO is indicated when the patient will not accept blood replacement for medical or religious reasons and the following symptoms are present:

  • shock
  • systolic blood pressure below 90mmHg, or pressure maintained by vasopressors
  • disorientation to coma
  • ischemic changes of the myocardium as demonstrated on the EKG
  • ischemic gut

HBO therapy is continued as needed and discontinued when the red blood cells have been replaced in numbers to alleviate the preceding signs and symptoms.

Osteoradionecrosis (bone necrosis caused by radiation)

Treatment: Utilization review is required after 60 treatments (sessions). Treatments are usually given daily for 90 to 120 minutes (1.5 hours to 2 hours).

Prevention: 20 pre-operative treatments (sessions) and 10 post-operative treatments (sessions).

Radiation necrosis

Utilization review is required after 60 treatments (sessions). Treatments are usually given daily for 90 to 120 minutes (1.5 hours to 2 hours).

Enhancement of healing in selected problem wounds

10 – 40 treatments (sessions)

Intracranial abscess

5 – 20 treatments (sessions)

Skin grafts and flaps (compromised)

6 – 40 treatments (sessions)

Necrotizing soft tissue infections (subcutaneous tissue, muscle, fascia)

5 – 30 treatments (sessions)

Thermal burns

5 – 45 treatments (sessions)

Gas or air embolism, acute

5 – 10 treatments (sessions)

Compartment syndrome

Twice/day for 24-36 hours.

(For residual complications after fasciotomy, twice/day for 7-10 days)

Chronic refractory osteomyelitis

Approximately 20-40 postoperative treatments should be delivered over a 4-6 week period.

REFERENCES:

  1. Agency for Healthcare Research and Quality. Comparative Effectiveness Review Number 26, Therapies for Children With Autism Spectrum Disorders (April, 2011)
  2. Agency for Healthcare Research and Quality. Evidence-based Practice Center Systematic Review Protocol Project Title: Evaluation and Treatment of Tinnitus: A Comparative Effectiveness Review (02/22/12).
  3. Agency for Healthcare Research and Quality. Comparative Effectiveness Report, Evaluation and Treatment of Tinnitus: A Comparative Effectiveness Review (02/22/12).
  4. Agency for Healthcare Research and Quality. Comparative Effectiveness Report, Pressure Ulcer Treatment Strategies: Comparative Effectiveness (05/13).
  5. American Cancer Society. Hyperbaric Oxygen Therapy. Accessed 04/15/14.
  6. American College of Hyperbaric Medicine Accepted Indications, (accessed 04/15/14).
  7. Bennett M, Best TM, Babul S, Taunton J. “Hyperbaric oxygen therapy for delayed onset muscle soreness and closed soft tissue injury” (updated 06/30/05).
  8. Bennett M, Feldmeier J, Smee R, Milross C. “Hyperbaric oxygenation for tumor sensitization to radiotherapy” (updated 06/16/05).
  9. Bennett M, Heard R. “Hyperbaric oxygen therapy for multiple sclerosis” (updated 04/15/04).
  10. Bennett M, Jepson N, Lehm JP. “Hyperbaric oxygen therapy for acute coronary syndrome” (updated 07/06/07).
  11. Bennett MH, Feldmeier J, Hampson N, Smee R, Milross C. “Hyperbaric oxygen therapy for late radiation tissue injury” (updated 05/23/05).
  12. Bennett MH, Standord R, Turner R. “Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non-union” (updated 11/11/04).
  13. Bennett MH, Trytko B, Jonker B. “Hyperbaric oxygen therapy for the adjunctive treatment of traumatic brain injury” (updated 06/16/04).
  14. Bennett MH, Wasiak J, Schnabel A, Kranke P, French C. “Hyperbaric oxygen therapy for acute ischemic stroke” (updated 03/21/05).
  15. Bennett MN, Kertesz T, Yeung P. Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus. (11/14/06).
  16. Blue Cross Blue Shield Association Medical Policy - Hyperbaric Oxygen Pressurization 2.01.04 (08/08/13).
  17. Blue Cross Blue Shield Association TEC Assessments, (1999; Tabs 13, 15, 16).
  18. Camporesi EM, Vezzani G, Bosco G, Mangar D, Bernasek TL. Hyperbaric oxygen therapy in femoral head necrosis. J Arthroplasty. 2010 Sep;25(6 Suppl):118-23. Epub 2010 Jul 15.
  19. Centers for Medicare & Medicaid Services (CMS) – National Coverage Determination for Hyperbaric Oxygen Therapy (20.29), (06/19/06).
  20. Centers for Medicare & Medicaid Services (CMS) Program Memorandum; Transmittal AB-02-183, “Coverage of HBO Therapy for Treatment of Diabetic Wounds of the Lower Extremities”, (06/19/06).
  21. ClinicalTrials.gov. Accessed 04/17/14.
  22. Cochrane Library: The Cochrane Database of Systematic Reviews 2008 Issue 1. Copyright © 2008. The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
  23. ECRI Institute. Target database report; HBOT for acute soft tissue injury, (published 08/06).
  24. ECRI Institute. Target database report; HBOT for radiation tissue damage, (published 08/98).
  25. ECRI Institute. Target database report; HBOT for traumatic brain injury, (published 09/06).
  26. ECRI Institute. Windows on Medical Technology. “HBO for Chronic Wound Healing”, (08/23/06).
  27. ECRI Health Technology Forecast – Hyperbaric oxygen treatment shows benefit for autism in first controlled trial (03/20/2009).
  28. Esposito M, Grusovin MG, Patel S, Worthington HV, Coulthard P. Interventions for replacing missing teeth: hyperbaric oxygen therapy for irradiated patients who require dental implants (11/01/07).
  29. Feldmeier JJ, Hope HW, Warriner RA, Fife CE, Gesell LB. Bennett M. Undersea Hyperbaric Medical Society Position Statement: Topical Oxygen for Chronic Wounds. UHM 2005, Vol. 32, No. 3.
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  31. First Coast Service Options (Local Medicare) LCD for Hyperbaric Oxygen Therapy (HBO Therapy) L29192 (02/02/09).
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COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 06/26/14.

GUIDELINE UPDATE INFORMATION:

01/01/01

Reformatted and revised - clarification of non-covered indications.

08/15/01

Revised to add clarification for HBO used for the prevention of osteoradioneurosis.

04/15/03

Reviewed and revised; ICD-9 diagnosis codes added; limitation changed.

01/01/04

Annual HCPCS coding update.

02/15/04

Revised coverage statement regarding prophylactic HBO.

04/15/05

Scheduled review; no change in coverage statement.

04/15/06

Scheduled review: no change in coverage statement; added reference to crushing head injuries.

04/15/07

Scheduled review; added ICD-9 diagnosis code 993.2; no change in coverage statement.

06/15/07

Reformatted guideline.

07/15/08

Scheduled review; no change in position statement; references updated.

09/15/09

Scheduled review; added additional indications and criteria information for covered indications; added criteria for continuation of HBO2 therapy; updated ICD-9 codes; updated references.

08/15/10

Accelerated review: position statement revised; ICD-9 list updated: references updated.

01/01/11

Revision; related ICD-10 codes added.

04/15/11

Revision of Position Statement to add clarification for HBO used for treating acute retinal arterial occlusion.

07/15/11

Revision; formatting changes.

08/15/12

Scheduled review; Position Statement updated to include additional indication; formatting revisions; references updated.

01/01/13

Annual HCPCS coding update: revised descriptor for 99183.

08/15/13

Scheduled review; position statement unchanged; Program Exceptions section updated; Reimbursement section updated; formatting changes; references updated.

07/15/14

Scheduled review; position statement unchanged; references updated.

01/01/15

Annual coding update: added G0277.

10/01/15

Revision; updated ICD9 and ICD10 coding section.

11/01/15

Revision: ICD-9 Codes deleted.

10/01/16

ICD-10 coding update; codes H90.A21 & H90.A22 added.

Date Printed: December 17, 2017: 10:10 PM