Archived Policies - Therapy


Hyperbaric Oxygen (HBO2) Pressurization

Number:THE801.003

Effective Date:11-01-2000

End Date:08-14-2007

Coverage:

Hyperbaric Oxygen (HBO2) Pressurization may be eligible for coverage as the primary mode of systemic therapy and all requests and claims must include documentation of medical necessity.

IF THE DIAGNOSIS IS:

THEN REVIEW:

Radiation necrosis or tissue damage (also known as osteoradionecrosis and soft tissue radiation necrosis),

After 20 treatments.

Decompression sickness,

After 5 days.

Acute carbon monoxide poisoning, smoke inhalation (not chronic), and carbon monoxide poisoning complicated by cyanide poisoning,

After 3 treatments.

Air or gas embolism,

After 5 treatments.

Gas gangrene, also known as Clostridial Myonecrosis (includes Meleney's postoperative gangrene ulcer),

After 3 treatments.

Chronic refractory osteomyelitis,

After 20 treatments.

Soft tissue infections due to mixed aerobic and anaerobic organisms with tissue necrosis and refractory bacteroides infections,

After 10 treatments.

Crush injury, compartment syndrome, and other acute traumatic ischemias,

After 4 treatments.

Compromised skin grafts or flaps or for enhancement of healing in selected problem wounds,

After 12 treatments.

Selected refractory mycoses (mucormycosis, actinomycosis, or canibolis coronato),

For individual consideration

Intracranial abscess,

For individual consideration

Acute cyanide poisoning,

For individual consideration

Acute cerebral edema,

For individual consideration

Diabetic wounds, which includes foot wounds or marginally perfused wounds,

After 12 treatments.

Venous stasis ulcers, only if venous surgery, local wound care, leg elevation, counterpressure support, and skin grafting fails,

For individual consideration

Decubitus ulcers,

For individual consideration

Arterial insufficiency ulcer which persists after reconstructive surgery has restored large vessel perfusion (includes peripheral vessels),

For individual

consideration

Brown recluse spider bites,

After 5 treatments.

Thermal burns, second or third degree burns involving 15 to 90% of total body surface and initiated within 24 hours of the burn injury,

After 5 treatments.

Anemia in exceptional circumstances, accepted medical practice when blood transfusion is impossible or must be delayed, or when loss due to hemolysis or exsanguination and the HCT is 23% or below,

For individual consideration

Special Policy Consideration on General Hyperbaric Oxygen Pressurization Therapy:  A course of treatment may range from less than one week to several months duration, depending on the severity of the patient's condition and response to therapy. 

Documentation must accompany requests and claims for treatment:

  • in excess of one-month duration,
  • in excess of the number of treatments previously listed or listed as individual consideration, and
  • must be reviewed for medical necessity.

Documentation must include at least two of the following:

  • photographs
  • consultation reports
  • operative or treatment reports and/or other applicable hospital records (examples - pathology report, history and physical)
  • office records
  • letters with pertinent information from:
    1. providers
    2. subscribers
    3. Local Medical Directors.  He/she may act as a liaison and present the case for review.

The prior approval process may be a useful method of establishing medical necessity.

Hyperbaric Oxygen (HBO2) Pressurization is not eligible for coverage as it is considered investigational for the following indications:

  • avascular necrosis,
  • retinal artery insufficiency, acute within the first 24 hours of diagnosis,
  • bone grafts,
  • carbon tetrachloride poisoning, acute,
  • cerebrovascular accident, acute thrombotic or embolic,
  • pseudomembranous colitis, antimicrobial agent-induced colitis,
  • meningitis,
  • head and spinal cord injury, traumatic,
  • Sickle cell crisis and/or hematuria,
  • fracture healing,
  • pyoderma gangrenosum,
  • intra-abdominal abscesses,
  • multiple sclerosis,
  • lepromatous leprosy,
  • Lyme disease,
  • myocardial infarction, acute,
  • hydrogen sulfide poisoning,
  • sudden deafness,
  • radiation myelitis, cystitis, enteritis, proctitis,
  • retinopathy, as an adjunct to scleral buckling procedure in patients with sickle cell peripheral retinopathy and retinal detachment.

Topical Hyperbaric Oxygen Therapy is not eligible for coverage as it is considered investigational.

Description:

Hyperbaric Oxygen (HBO2) Pressurization Therapy is a technique of delivering higher pressures of oxygen to the tissues. Two methods of delivery are available, systemic and topical.

In systemic or large chamber HBO2, the patient is entirely enclosed in a pressure chamber and breathes pure oxygen at a pressure greater than one atmosphere (the pressure of oxygen at sea level). This technique relies on systemic circulation to deliver highly oxygenated blood to the target site, typically a wound.  In addition, systemic HBO2 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 (single patient unit) chamber pressurized with pure oxygen or in a larger, multiplace (multiple patient unit) chamber pressurized with compressed air, in which case the patient receives pure oxygen by mask, head tent, or endotracheal tube. (NOTE:  Breathing 100% oxygen at one atmosphere WITHOUT the use of a pressurized chamber is NOT considered to be HBO2 pressurization.)

Topical HBO2 therapy describes a technique of delivering 100% oxygen directly to an open, moist wound at a pressure slightly higher than atmospheric pressure. It is hypothesized that high concentrations of oxygen diffused directly into the wound, increases the local cellular oxygen tension, which in turn promotes wound healing. Topical HBO2 devices consist of an appliance to enclose the wound area (frequently an extremity) and a source of oxygen. The appliances may be disposable and may be used without supervision in the home by well-trained patients. Topical HBO2 therapy has been investigated as a treatment of skin ulcerations due to diabetes, venous stasis, postsurgical infection, gangrene, decubitus, compromised amputations or skin grafts, burns, or frostbite.

HBO2 is a generally accepted medical treatment. HBO2 services include both consultative and therapeutic services. The HBO2 Physician, certified by the American College of Hyperbaric Medicine and American College of Preventive Medicine, must be actively present during all treatments.

The hospital based HBO2 facility must be in full compliance with all standards set forth by the Accreditation Manual for Hospitals (JCAHO). The freestanding HBO2 facility should be in verified conformation with local community hospital quality assurance and continuous quality improvement standards. Every HBO2 facility must have a physician who has been designated as the Medical Director.

Rationale:

Due to the different methods of delivery, topical and systemic HBO2 are TWO distinct technologies. Outcomes associated with systemic HBO2 therapy cannot be duplicated by topical therapy.

There is minimal published literature regarding topical HBO2 therapy. In one controlled study, the changes in ulcer size and depth did not differ between topical HBO2 therapy and no treatment. Other studies consist of anecdotal reports or uncontrolled case series.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

None


Medicare Coverage:

The information contained in this section is for informational purposes only.  HCSC makes no representation as to the accuracy of this information.  It is not to be used for claims adjudication for HCSC plans.

References:

Grim, P.S., et al. Hyperbaric oxygen therapy. The Journal of the American Medical Association (1990 April 25) 263(16): 2216-20.

Kindwall, E.P. Hyperbaric oxygen. British Medical Journal (Clinical Research Edition) (1993 August 28) 307(6903): 515-6.

First European Consensus Conference Which Acute indications for Hyperbaric Oxygen Therapy? 1994. Prepared by the Jury (Web Site/on-line): ttp://www.awurweb.com/medsubhyp/cecen1.htm.

Medscape Hyperbaric Oxygen and Thrombolysis in Myocardial Infarction: The HOT MI Pilot Study. 1997. Prepared by Departments of Cardiology and Baromedicine, Long Beach Memorial Medical Center and the University of California, Irvine (American Heart Journal 134[3]: 544-50) (Web Site/on-line): http://news.medscape.com/mosby/AmHeartJ/I…n03/ahj1343.shan.html.

Diving Medicine Online Approved Indications for HBO Therapy. 1998. Prepared by Ernest S. Campbell, M.D., F.A.C.S. (Web Site/on-line): http://www.gulftel.com/~scubadoc/HBOInd.htm.

Undersea and Hyperbaric Medical Society Indications for Hyperbaric Oxygen Therapy. 1998 Prepared by the HBO2 Therapy Committee, Neil B. Hampson, M.D., Chairman (Web Site /on-line): http://www.uhms.org.

Hyperbaric Oxygen Pressurization (HBO2). BCBSA Consortium Health Plan Medical Policy Reference Manual (1998 December 15) Surgery:  2.01.04.

National Baromedical Services All About Hyperbaric Medicine. 1999 Prepared by The Baromedical Research Foundation (Web Site/on-line): http://www.baromedical.com.

HCFA Hyperbaric Oxygen Therapy 35-10. 1999. Prepared by Health Care Financing Agency - Coverage Issues Manual (Web Site/on-line): ttp://www.hcfa.gov/pubforms/06%5Fcim/ci35.htm.

American College of Hyperbaric Medicine Issue Paper: Medicare Accepted Indications. April 1999 Prepared by the American College of Hyperbaric Medicine (Web Site/on-line): http://www.hyperbaricmedicine.org/Indications.htm

Policy History:

Archived Document(s):

Title:Effective Date:End Date:
Hyperbaric Oxygen (HBO2) Therapy07-15-201709-30-2018
Hyperbaric Oxygen (HBO2) Therapy10-01-201607-14-2017
Hyperbaric Oxygen (HBO2) Therapy05-01-201509-30-2016
Hyperbaric Oxygen (HBO2) Pressurization12-01-201304-30-2015
Hyperbaric Oxygen (HBO2) Pressurization07-15-201111-30-2013
Hyperbaric Oxygen (HBO2) Pressurization03-01-201007-14-2011
Hyperbaric Oxygen (HBO2) Pressurization09-15-200802-28-2010
Hyperbaric Oxygen (HBO2) Pressurization08-15-200709-14-2008
Hyperbaric Oxygen (HBO2) Pressurization11-01-200008-14-2007
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