Archived Policies - Therapy


Hyperbaric Oxygen (HBO2) Pressurization

Number:THE801.003

Effective Date:07-15-2011

End Date:11-30-2013

Coverage:

Therapy with systemic hyperbaric oxygen (HBO2) pressurization may be considered medically necessary for the medical conditions and circumstances listed below.  ALL requests and claims must include documentation of medical necessity. 

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

The medical conditions and circumstances that may be considered medical necessary are listed in the grid below.  This includes the number of treatments initially allowed for each approved condition.  Approval of treatment or services beyond the number initially authorized requires review of pertinent medical record documentation.  Additional information about these requirements is contained within the policy document.

IF THE DIAGNOSIS IS:

THEN REVIEW:

Chronic refractory osteomyelitis,

After 20 treatments.

Soft-tissue radiation necrosis (i.e., radiation enteritis, cystitis, proctitis) and osteoradionecrosis.

NOTE 1: Radiation necrosis: review is required after each 20 treatments.  Treatments are usually given daily for 90 to 120 minutes.  Beyond 60 treatments, individual consideration is applied. 

After 20 treatments.

(see NOTE 1)

 

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

After 12 treatments.

 

Diabetic wounds, which include foot wounds or marginally perfused wounds, non-healing of the lower extremities in diabetic patients who meet ALL the following three criteria:

  • Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes, AND
  • Patient has a wound classified as Wagner grade-3 or higher (see NOTE 2), AND
  • Patient has no measurable signs of healing after 30 days of an adequate course of standard wound therapy.

NOTE 2:  The Wagner classification system of wounds is defined as follows:

  • 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; and,
  • 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.

After 30 treatments.

 

Gas gangrene (i.e., clostridial myonecrosis) and includes Meleney's postoperative gangrene ulcer).

After 10 treatments.

 

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

After 10 treatments.

 

 

Acute air or gas embolism.

After 5 treatments.

Brown recluse spider bites.

After 5 treatments.

Acute carbon monoxide poisoning (intoxication) and smoke inhalation (not chronic).

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.

 

 

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

NOTE 3:  Acute traumatic ischemia: three treatments per day for 48 hours followed by two treatments per day over the second 48 hours and one treatment per day over the third period of 48 hours.  Beyond this time period, individual consideration is applied.

After 12 treatments.

(see NOTE 3)

Decompression sickness.

NOTE 4:  Decompression sickness: 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 ranges from 1.5 to 14.0 hours.  Repetitive treatments may be necessary, depending on the patient’s response.

After 5 days.

(see NOTE 4)

Venous stasis ulcers, only if venous surgery, local wound care, leg elevation, counterpressure support, and skin grafting fails for patients who have a wound classified as Wagner grade-3 or higher (see NOTE 2).

NOTE 2:  The Wagner classification system of wounds is defined as follows:

  • 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; and,
  • 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.

After 12 treatments.

(see NOTE 2)

 

 

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

For individual consideration of number of treatments.

Intracranial abscess.

For individual consideration of number of treatments.

Acute cyanide poisoning.

For individual consideration of number of treatments.

Acute cerebral edema.

For individual consideration of number of treatments.

Arterial insufficiency ulcer (not acute) which persists after reconstructive surgery has restored large vessel perfusion (includes peripheral vessels).

For individual consideration of number of treatments.

 

Decubitus ulcers.

For individual consideration of number of treatments.

Exceptional blood loss anemia, for class IV hemorrhage, HBO2 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 90 mm Hg, or pressure maintained by vasopressors; AND
  • Disorientation to coma; AND
  • Ischemic changes of the myocardium as demonstrated on the electrocardiogram (EKG);  AND
  • Ischemic gut.

NOTE 5:  Exceptional blood loss anemia: HBO2 therapy is continued as needed and discontinued when the red blood cells have been replaced in numbers to alleviate the precipitating signs and symptoms.

For individual consideration of number of treatments.

(see NOTE 5)

Pre- and post-treatment for patients undergoing dental surgery (non-implant related) of an irradiated jaw.

For individual consideration of number of treatments.

COMMENT:  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.  The average length of treatment is two to four weeks.  Systemic HBO2 Therapy for more than two months is considered not medically necessary.

ALL the following documentation requirements for systemic HBO2 pressurization therapy must ACCOMPANY requests and claims for treatment:

  • when services are in excess of one-month duration; AND/OR
  • when services are in excess of the number of treatments previously listed or listed as individual consideration; AND
  • documentation must be reviewed for medical necessity; AND
  • documentation must include at least two of the following:
    1. photographs, AND/OR
    2. consultation reports, AND/OR
    3. operative or treatment reports and/or other applicable hospital records (e.g., pathology report, history and physical), AND/OR
    4. office records.

Systemic HBO2 pressurization therapy is considered experimental, investigational and unproven, including but not limited to the following indications or clinical conditions and any diagnosis not previously listed as covered:

  • actinic keratosis (AK) or actinic skin damage,
  • amyotrophic lateral sclerosis (ALS);
  • arterial peripheral insufficiency, acute;
  • autistic spectrum disorders (ASD);
  • avascular necrosis;
  • bone grafts;
  • carbon tetrachloride poisoning, acute;
  • cerebral palsy (CP);
  • cerebrovascular accident (CVA), acute thrombotic or embolic, or chronic;
  • coronary syndromes, acute, and as an  adjunct to coronary interventions, including but not limited to percutaneous coronary interventions (PCI) and cardiopulmonary bypass;
  • Crohn’s disease, severe or refractory;
  • fracture healing;
  • head (brain) and spinal cord injury, traumatic;
  • hydrogen sulfide poisoning;
  • ileus (postoperative);
  • intra-abdominal abscesses;
  • in vitro fertilization (IVF);
  • ischemic stroke, acute;
  • lepromatous leprosy;
  • Lyme disease (LD);
  • meningitis;
  • migraine or cluster headaches;
  • multiple sclerosis (MS);
  • muscle soreness, delayed onset;
  • myocardial infarction (MI), acute;
  • pancreatitis (acute);
  • pseudomembranous colitis, antimicrobial agent-induced colitis;
  • pyoderma gangrenosum;
  • retinal artery insufficiency, acute within the first 24 hours of diagnosis;
  • radiation-myelitis;
  • retinopathy, as an adjunct to scleral buckling procedure in patients with sickle cell peripheral retinopathy and retinal detachment;
  • Sickle cell crisis (SCC) and/or hematuria;
  • sudden deafness and/or idiopathic sudden sensorineural hearing loss; AND
  • tumor sensitization for cancer treatments, include but not limited to, radiotherapy or chemotherapy.

Therapy with topical HBO2 (THBO2) pressurization for any indication or clinical condition is considered experimental, investigational and unproven.

Description:

Hyperbaric Oxygen (HBO2) pressurization therapy is a technique of delivering higher pressures of oxygen (O2) 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 O2 at a pressure greater than one atmosphere (the pressure of O2 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 O2 or in a larger, multiplace (multiple patient unit) chamber pressurized with compressed air, in which case the patient receives pure O2 by mask, head tent, or endotracheal tube.  A cycle of pressurization, with or without air breaks, inside an HBO chamber may be called “a dive”, which may last for 90 minutes or more.  (NOTE:  Breathing 100% O2 at one atmosphere WITHOUT the use of a pressurized chamber is NOT considered to be HBO2 pressurization.)

THBO2 therapy describes a technique of delivering 100% O2 directly to an open, moist wound at a pressure slightly higher than atmospheric pressure.  It is hypothesized that high concentrations of O2 diffused directly into the wound, increases the local cellular O2 tension, which in turn promotes wound healing.  THBO2 devices consist of an appliance to enclose the wound area (frequently an extremity) and a source of O2.  The appliances may be disposable and have been used without supervision in the home.  Typically, the therapy is offered for 90 minutes per day for four consecutive days.  After a three-day break, the cycle is repeated.  This regimen may last for eight- to ten-weeks.  THBO2 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.

Systemic 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.

Rationale:

The original policy on systemic HBO2 was based upon the 1996 guidelines published by the Undersea and Hyperbaric Medical Society (UHMS).  The UHMS published new guidelines in June 2003 in which their Hyperbaric Oxygen Therapy Committee continues to consider HBO to be appropriate for these conditions:

  • Air or gas embolism;
  • Carbon monoxide poisoning and carbon monoxide complicated by cyanide poisoning;
  • Clostridal myositis and myonecrosis (gas gangrene);
  • Crush injury, compartment syndrome and other acute traumatic ischemias;
  • Decompression sickness;
  • Enhancement of healing in selected problem wounds;
  • Exceptional blood loss (anemia);
  • Intracranial abscess;
  • Necrotizing soft tissue infections;
  • Osteomyelitis (refractory);
  • Delayed radiation injury (soft tissue and bony necrosis);
  • Skin grafts and flaps (compromised); AND
  • Thermal burns.

As of the January 2007 update, the UHMS has not changed their indications for systemic HBO2 pressurization therapy from those conditions listed above.  Literature also states systemic HBO2 should not replace standard, successful therapeutic treatment courses, used to treat conditions that will improve under higher oxygen pressurization to body tissues. 

The literature review also examined the role of systemic HBO2 as a treatment modality for indications listed as experimental, investigational and unproven.  This includes, but is not limited to, acute ischemic stroke, acute coronary syndromes as an adjunct to PCI, idiopathic sudden sensorineural hearing loss, migraine, ALS, IVF, CD, acute peripheral arterial insufficiency, and CP.

Rusyniak and colleagues reported on the results of a randomized, double-blind sham-controlled study of 33 patients presenting with acute ischemic stoke who were randomized to active or sham HBO2.  No beneficial effect was reported for HBO2

Sharifi and colleagues reported on a trial that randomized 69 patients with unstable angina or acute MI to receive or not receive HBO2 after PCI.  The rationale behind this investigation was that HBO2 therapy might accelerate the healing of the microtrauma associated with PCI and thus ultimately reduces the restenosis rate.  The 24 patients randomized to the HBO2 group reported only one adverse event (death, MI, coronary artery bypass, or revascularization of target lesion), compared to 13 in the 37 control patients.  However, this study lacks adequate detail to provide scientific conclusions.  For example, details of the type of PCI performed, such as whether a drug eluting stent was used, were not provided.  In addition, a Cochrane review of four trials with a total of 462 patients concluded there were no significant benefits for patients with acute coronary syndromes receiving HBO2

Topuz and colleagues reported on a trial that randomized 51 patients with sudden idiopathic sensorineural hearing loss to receive conventional therapy, such as steroids, plasma expanders, with or without HBO2.  Audiologic assessments were performed immediately after treatment.  While the HBO2 group reported gains in hearing at some frequencies, this small trial with short follow-up is inadequate to permit scientific conclusions.  A Cochrane review of five trials with a total 254 patients also concluded that the data are insufficient to determine the clinical significance of hearing improvement with the use of HBO2 therapy in patients with idiopathic sensorineural hearing loss. 

In a randomized, double-blind, placebo-controlled study of 40 patients, Eftedal and colleagues reported no significant reductions in migraine occurrence with HBO2 therapy compared to hyperbaric air treatments. 

Steele et al. treated five patients with ALS with HBO2 and reported some improvements in fatigue but noted further study is needed and attention to placebo effects must be given. 

Van Voorhis and colleagues reported HBO2 was well tolerated in women undergoing ovarian follicular stimulation for IVF, however, no outcomes were reported, and further study is needed.

The 1999 Blue Cross Blue Shield Association (BCBSA) Technology Evaluation Center (TEC) Assessment reported the available evidence supporting severe or refractory CD consisted of case reports, small uncontrolled case series, and one case-controlled report that observed intermediate outcomes only.  The TEC Assessment concluded that there was insufficient evidence to permit conclusions.

No clinical trial publications were identified that demonstrated benefit in HBO2 therapy for acute peripheral arterial insufficiency, and thus the evidence basis for coverage by Medicare is unclear as Medicare has long listed acute peripheral arterial insufficiency as a medically necessary indication.  Due to the lack of published literature, acute peripheral arterial insufficiency is listed as an experimental, investigational and unproven indication.

Collet et al randomized 111 children with CP to 40 treatments over a two-month period of either HBO2 or slightly pressurized room air.  The authors found HBO2 therapy produced similar improvements in outcomes such as gross motor function and activities of daily living in both groups.

During the 2007 update, the literature review revealed additional indications utilizing HBO2 therapy.  In a randomized controlled trial (RCT) of 32 patients, Heys and colleagues found no increase in five-year survival in patients treated with HBO2 prior to chemotherapy for locally advanced breast carcinoma to increase tumor vascularity.  This approach is being studied since animal models have suggested that HBO2 increases tumor vascularity and thus may make chemotherapy more effective.  In a Cochrane review, Bennett and colleagues concluded HBO2 given with radiotherapy may be useful in tumor control; however, the authors expressed caution since significant adverse effects were common with HBO2 and indicated further study would be useful.

In another Cochrane review, Bennett and colleagues concluded available evidence is insufficient to demonstrate beneficial outcomes with HBO2 for delayed-onset muscle soreness and closed soft tissue injury.  It was noted HBO2 possibly even increases pain initially and further studies are needed. 

In an RCT of 64 patients, Alex and colleagues concluded both neuropsychometric dysfunction and inflammatory response can be reduced post-cardiopulmonary bypass when HBO2 pretreatment is given.  However, the authors noted additional studies were needed to evaluate HBO2 for this indication.  Therefore the experimental, investigational and unproven statement on acute coronary syndromes was modified to specify “as an adjunct to coronary interventions, including but not limited to percutaneous coronary interventions and cardiopulmonary bypass”.

In a systematic review, Carson and colleagues concluded current available evidence does not demonstrate any benefit with the use of HBO2 therapy for the treatment of stroke.  The authors noted it is undetermined whether there are any benefits with HBO2 therapy that would outweigh potential harms and further study is required.  In a non-randomized, controlled trial of 26 patients treated with or without HBO2 for symptomatic cerebrovascular disease, Vila and colleagues concluded HBO2 therapy improved neurologic outcomes for up to six-months.  However, the authors noted further study in larger patient groups is needed.

In another systematic review, Bennett and colleagues concluded that there was “some evidence that HBO2 improves the probability of healing in radiation proctitis and following hemimandibulectomy and reconstruction of the mandible; improves the probability of achieving mucosal coverage and the restoration of bony continuity with ORN (osteoradionecrosis); prevents the development of ORN following tooth extraction from a radiation field; and reduces the risk of wound dehiscence following grafts and flaps in the head and neck”.  They concluded that there was no benefit using HBO2 in important clinical outcomes with radiation brachial plexus lesions or cerebral tissue injury.  No data was reported from randomized trials for other manifestations of late radiation tissue injury.  Given the small size of many of these trials, the extended time periods of reporting, and the poor methodological quality of some studies, no changes were made in the coverage position.

One published article discussed use of HBO2 therapy in combination with photosensitization and iron to treat actinic skin damage or AK.  Al-Walili and colleagues discuss the advantages photodynamic therapy as the new approach to treatment of malignant tumors in addition to the beneficial effects of HBO2 in various modalities of cancer interventions.  No data was reported from randomized trials for treatment of AK.  The authors noted the possibility of combining HBO2, iron, light, and local photosensitizers to overcome skin tumors deserve extensive laboratory and clinical research work.

The March 2003 Information Paper, produced by Alberta Heritage Foundation for Medical Research (AHFMR), Alberta, Canada government sponsored research programs, reviewed recent findings on evidence for the effectiveness of HBO2 therapy as a Health Technology Assessment. The AHEMR conclusions are as follows.

  • “There is support for use of HBO2 in for the following conditions: Decompression sickness, air and gas embolism, and gas gangrene.”
  • “There is conditional support for use of HBO2 in: Carbon monoxide poisoning, osteoradionecrosis, diabetic wounds, necrotizing soft tissue infections.”
  • “There is no consensus on support for use of HBO2 in: Osteomyelitis, thermal burns, soft tissue radionecrosis, compromised skin grafts and flaps, dental implants following radiotherapy, retinal artery occlusion.”
  • “Use of HBO2 is not supported for: Crush injury, non-diabetic wounds, MS, CP, or for a large number of conditions, including but not limited to:  decubitus ulcers, necrotizing arachnidism, actinomycosis, cardiovascular conditions, Bell’s palsy, cluster or migraine headaches, Legg-Calve-Perthes disease, sudden deafness and acoustic trauma, Crohn’s disease, osteoporosis, cancer cyanide poisoning, head trauma, cerebral edema, acquired brain injury, cognitive impairment, senile dementia, glaucoma, keratoendotheliosis, HIV infection, anemia from exceptional blood loss, insulin-dependent diabetes mellitus, facial neuritis, arthritis, spinal injuries, and non-union of fractures.”

Therefore, there is a lack of scientific evidence from which conclusions can be made concerning the safety and efficacy of utilizing HBO2 therapy for various other indications mentioned as clinical conditions and not a labeled indication by the FDA nor listed on the guidelines from UHMS, such as:

  • AK; OR
  • avascular necrosis; OR
  • arterial peripheral insufficiency, acute; OR
  • ASD; OR
  • bone grafts; OR
  • carbon tetrachloride poisoning, acute; OR
  • CVA, acute thrombotic or embolic, acute; OR
  • fracture healing; OR
  • head and spinal cord injury, traumatic; OR
  • hydrogen sulfide poisoning; OR
  • intra-abdominal abscesses; OR
  • lepromatous leprosy; OR
  • LD; OR
  • Meningitis; OR
  • MS; OR
  • MI, acute; OR
  • pseudomembranous colitis, antimicrobial agent-induced colitis; OR
  • pyoderma gangrenosum; OR
  • retinal artery insufficiency, acute within the first 24 hours of diagnosis; OR
  • radiation-myelitis, -cystitis, -enteritis, -proctitis; OR
  • retinopathy, as an adjunct to scleral buckling procedure in patients with sickle cell peripheral retinopathy and retinal detachment; OR
  • SCC and/or hematuria; OR
  • sudden deafness.

Further research with randomized, controlled, clinical trials is required to determine achievable outcomes outside the investigational setting.

In some studies, cerebral hypoperfusion has been correlated with repetitive, self-stimulatory, and stereotypical behaviors, and impairments in communication, sensory perception, and social interaction.  HBO2 therapy has been used with some clinical success in several cerebral hypoperfusion conditions.  Several studies on the use of HBO2 therapy, and HBO2 therapy in combination with chelation, in autistic children are currently underway.  In 2007, Rossignol et al. conducted a prospective study of 18 children with autism, ages 3-16 years, who were given 40 HBO2 therapy sessions of 45 minutes each, either at 1.5 atmospheres (atm) and 100% oxygen, or at 1.3 atm and 24% oxygen.  Although some of the results did appear to be positive, the authors concluded that, since this was an open-label study, definitive statements regarding the efficacy of HBO2 therapy for the treatment of autism must await results from double-blind, controlled trials.

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 THBO2 therapy. In 1984, Heng and colleagues published one controlled study of THBO2 therapy in six patients with 27 ulcers compared to no treatment in five patients with ten ulcers.  Although a greater improvement was noted in the treated group, the results were calculated according to the number of ulcers rather than based on individual patients.  Leslie and colleagues reported on a trial that randomized 18 patients with diabetic foot ulcers to receive either THBO2 therapy plus standard wound care or standard wound care alone.  Changes in ulcer size and depth did not differ between the two groups.  Other studies consist of anecdotal reports or uncontrolled case series.   

October 2009 Update

A search of peer reviewed literature through October 2009 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.  Reports of uncontrolled studies, some from outside the United States, are reporting preliminary results for use of hyperbaric oxygen in other conditions such as postoperative ileus and acute pancreatitis.

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:

HCPCS code A4575 is used to describe the disposable appliance that is positioned around the wound area for THBO2 therapy.  Conventional O2 tanks, typically gas, are used to supply the O2.

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

99183

HCPCS Codes

A4575

ICD-9 Diagnosis Codes

008.49, 030.0, 039, 039.0, 039.1, 039.2, 039.3, 039.4, 039.8, 039.9, 040.0, 088.81, 090.0, 095.5, 111, 111.0, 111.1, 111.2, 111.3, 111.8, 111.9, 112, 112.0, 112.1, 112.2, 112.3, 117.9, 282.62, 285.1, 299.00, 299.01, 299.10, 299.11, 299.80, 299.81, 299.90, 299.11, 312.00, 312.01, 312.02, 312.03, 312.10, 312.11, 312.12, 312.13, 312.20, 312.21, 312.22, 312.23, 312.30, 312.34, 312.35, 312.4, 312.81, 312.82, 312.89, 312.9, 313.0, 313.1, 313.21, 313.22, 313.23, 313.3, 313.81, 313.82, 313.83, 313.89, 313.9, 315.31, 315.32, 315.39, 315.4, 315.5, 315.8, 315.9, 317, 318.0, 318.1, 318.2, 319, 322.9, 323.9, 324.0, 340, 348.5, 348.8, 362.10, 376.03, 388.2, 410.9, 436, 444.9, 447.2, 454.0, 459.0, 459.9, 526.4, 526.89, 558.1, 560.1, 560.8, 560.9, 564.8, 567.2, 569.49, 577.0, 593.81, 595.82, 682, 682.0, 682.1, 682.2, 682.3, 682.4, 682.5, 682.6, 682.7, 682.8, 682.9, 686, 686.0, 686.00, 686.01, 686.09, 686.1, 686.8, 686.9, 707.0, 728.86, 730, 730.0, 730.00, 730.01, 730.02, 730.03, 730.04, 730.05, 730.06, 730.07, 730.08, 730.09, 730.1, 730.10, 730.11, 730.12, 730.13, 730.14, 730.15, 730.16, 730.17, 730.18, 730.19, 730.2, 730.20, 730.21, 730.22, 730.23, 730.24, 730.25, 730.26, 730.27, 730.28, 730.29, 730.8, 730.80, 730.81, 730.82, 730.83, 730.84, 730.85, 730.86, 730.87, 730.88, 730.89, 759.83, 767.0, 767.8, 767.9, 783.40, 783.42, 785.4, 803.00, 854.00, 879.8, 925, 925.1, 925.2, 926, 926.0, 926.1, 926.11, 926.12, 926.19, 926.8, 926.9, 927, 927.0, 927.00, 927.01, 927.02, 927.03, 927.09, 927.1, 927.10, 927.11, 927.2, 927.20, 927.21, 927.3, 927.8, 927.9, 928, 928.0, 928.00, 928.01, 928.1, 928.10, 928.11, 928.2, 928.20, 928.21, 928.3, 928.8, 928.9, 929, 929.0, 929.9, 948, 948.0, 948.1, 948.10, 948.11, 948.2, 948.20, 948.21, 948.3, 948.30, 948.31, 948.32, 948.33, 948.4, 948.40, 948.41, 948.42, 948.43, 948.44, 948.5, 948.50, 948.51, 948.52, 948.53, 948.54, 948.55, 948.6, 948.60, 948.61, 948.62, 948.63, 948.64, 948.65, 948.66, 948.7, 948.70, 948.71, 948.72, 948.73, 948.74, 948.75, 948.76, 948.77, 948.8, 948.80, 948.81, 948.82, 948.83, 948.84, 948.85, 948.86, 948.87, 948.88, 948.9, 948.90, 948.91, 948.92, 948.93, 948.94, 948.95, 948.96, 948.97, 948.98, 948.99, 949.0, 952.9, 958.0, 958.8, 959.01, 959.09, 986, 986.0, 987.8, 987.9, 989.0, 989.5, 990, 993.3, 996.4, 996.52, 996.55, 996.69, 996.7, 996.78, 996.79, 997.4, V18.4, V19.5, V40, V45.89, V54.9     

ICD-9 Procedure Codes

93.95, 93.96

ICD-10 Diagnosis Codes

 

ICD-10 Procedure Codes

 


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.

The Centers for Medicare and Medicaid Services (CMS) does have a national Medicare coverage position.

A national coverage position for Medicare may have been changed since this medical policy document was written.  See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

Heng, M.C., Pilgrim, J.P., et al.  A simplified hyperbaric oxygen technique for leg ulcers.  Archives of Dermatology (1984 May) 120(5):640-5.

Leslie, C.A., Sapico, F.L., et al.  Randomized controlled trial of topical hyperbaric oxygen for the treatment of diabetic foot ulcers.  Diabetes Care (1988 February) 11(2):111-5.

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

Heng, M.C.  Topical hyperbaric therapy for problem skin wounds.  Journal of Dermatologic Surgery and Oncology (1993 August) 19(8):784-93.

Verrazzo, G., Coppola, L., et al.  Hyperbaric oxygen, oxygen-ozone therapy, and rheologic parameters of blood in patients with peripheral occlusive arterial disease.  Undersea and Hyperbaric Medicine (1995 March) 22(1):17-22.

Scuba-Doc.com – Diving Medicine Online Approved Indications for HBO Therapy  (1996). Prepared by Ernest S. Campbell, M.D., F.A.C.S. (accessed – 1998) <http://www.scuba-doc.com>.

Tibbles, P.M., and J.S. Edelsberg.  Medical progress: Hyperbaric-oxygen therapy.  The New England Journal of Medicine (1996 June 20) 334(25):1642-8.

Shandling, A.H., Ellestad, M.H., et al.  Hyperbaric oxygen and thrombolysis in myocardial infarction: The 51HOT MI51 pilot study.  American Heart Journal (1997 September) 134(3):544-50.

UHMS.com – Hampton, N.B., chairman, Indications for Hyperbaric Oxygen Pressurization (1998).  Undersea and Hyperbaric Medical Society, HBO2 Therapy Committee.  (accessed – 1998) <http://www.uhms.org>.

Landau, W.  Topical hyperbaric oxygen and low energy laser for the treatment of diabetic foot ulcers.  Archives of Orthopaedic and Traumatic Surgery (1998) 117(3):156-8.

BaroMedical.com – All About Hyperbaric Medicine (1999).  Prepared by The Baromedical Research Foundation (accessed – 1999).  <http://www.baromedical.com>.

Scheinkestel, C.D., Bailey, M., et al.  Hyperbaric or normobaric oxygen for acute carbon monoxide poisoning: A randomized controlled clinical trial.  Medical Journal of Australia (1999 March 1) 170(5):203-10.

HyperbaricMedicine.org – Medicare Accepted Indications (1999 April).  Prepared by the American College of Hyperbaric Medicine (accessed – 1999) <http://www.hyperbaricmedicine.org>.

Hyperbaric Oxygen Therapy for Wound Healing – Part I.  Chicago, Illinois: Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (1999 August) 14(13):1-55.

Tong, A.C., Leung, A.C., et al.  Incidence of complicated healing and osteoradionecrosis following tooth extraction in patients receiving radiotherapy for treatment of nasopharyngeal carcinomas.  Australian Dental Journal (1999 September) 44(3):187-94.

Hyperbaric Oxygen Therapy for Wound Healing – Part II.  Chicago, Illinois: Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (1999 December) 14(15):1-55.

Hyperbaric Oxygen Therapy for Wound Healing – Part III.  Chicago, Illinois: Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (1999 December) 14(16):1-27.

Collet, J.P., Vanasse, M., et al.  Hyperbaric oxygen for children with cerebral palsy: A randomized multicenter trial.  HBO-CP Research Group.  Lancet (2001 February 24): 357(9256): 582-6.

Pritchard, J., Anand, P., et al.  Double-blind randomized phase II study of hyperbaric oxygen in patients with radiation-induced brachial plexopathy.  Radiotherapy and Oncology (2001 March) 58(3):279-86.

Landau, Z., and A. Schatter.  Topical hyperbaric oxygen and low energy laser therapy for chronic diabetic foot ulcers resistant to conventional treatment.  Yale Journal of Biology and Medicine (2001 March-April) 74(2):95-100.

Feldmeier, J.J., and N.B. Hampson.  A systematic review of the literature reporting the application of hyperbaric oxygen prevention and treatment of delayed radiation injuries: An evidence based approach.  Undersea and Hyperbaric Medicine (2002 Spring) 29(1):4-30.

Weaver, L.K., Hopkins, R.O., et al.  Hyperbaric oxygen for acute carbon monoxide poisoning.  New England Journal of Medicine (2002 October 3) 347(14):1057-67.

Edsberg, L.E., Brogan, M.S., et al.  Topical hyperbaric oxygen and electrical stimulation: exploring potential synergy.  Ostomy Wound Management (2002 November) 48(11):42-50.

Rusyniak, D.E., Kirk, M.A., et al.  Hyperbaric oxygen therapy in acute ischemic stroke: results of the Hyperbaric Oxygen in Acute Ischemic Stroke Trial Pilot Study.  Stroke (2003 February) 34(2):571-4.

Hyperbaric Oxygen Therapy – Recent Findings on Evidence for its Effectiveness.  Calgary, Alberta, Canada: Alberta Heritage Foundation for Medical Research – Information Paper, Health Technology Assessment (2003 March) IP 13:1-25.

UHMS.com – Indications for Hyperbaric Oxygen Pressurization (2003 June).  Undersea and Hyperbaric Medical Society, HBO2 Therapy Committee. (accessed – 2006 November 30) <http://www.uhms.org>.

Reuther, T., Schuster, T., et al.  Osteoradionecrosis of the jaw as a side effect of radiotherapy of head and neck tumor patients – A report of a thirty year retrospective review.  International Journal of Oral and Maxillofacial Surgery (2003 June) 32(3):289-95.

Gordillo, G.M., and C.K. Sen.  Revisiting the essential role of oxygen in wound healing.  American Journal of Surgery (2003 September) 186(3):259-63.

Kranke, P., Bennett, M., et al.  Hyperbaric oxygen therapy for chronic wounds.  Cochrane Database Systematic Review (2004) (2):CD004123.

Sharifi, M., Fares, W., et al.  Usefulness of hyperbaric oxygen therapy to inhibit restenosis after percutaneous coronary intervention for acute myocardial infarction or unstable angina pectoris.  American Journal of Cardiology (2004 June 15) 93(12):1533-5.

Eftedal, O.S., Lydersen, S., et al.  A randomized, double blind study of the prophylactic effect of hyperbaric oxygen therapy on migraine.  Cephalalgia (2004 August) 24(8):639-44.

Topuz, E., Yigit, O., et al.  Should hyperbaric oxygen be added to treatment of idiopathic sudden sensorineural hearing loss?  European Archives of Oto-Rhino-Laryngology (2004 August) 261(7):393-6.

Kao, L.W., and K.A. Nanagas.  Carbon monoxide poisoning.  Emergency Medicine Clinics of North America (2004 November) 22(4):985-1018.

Greensmith, J.E.  Hyperbaric oxygen therapy in extremity trauma.  Journal of the American Academy of Orthopedic Surgery (2004 November-December) 12(6):376-84.

Steele, J., Matos, L.A., et al.  A Phase I safety study of hyperbaric oxygen therapy for amyotrophic lateral sclerosis.  Amyotrophic Lateral Sclerosis and Other Motor Neuron Disorders (2004 December) 5(4):250-4.

Annane, D., Depondt, J., et al.  Hyperbaric oxygen therapy for radionecrosis of the jaw: A randomized, placebo-controlled, double-blind trial from the ORN96 study group.  Journal of Clinical Oncology (2004 December 15) 22(24):4893-900.

Wilkinson, D., and D. Doolette.  Hyperbaric oxygen treatment and survival from necrotizing soft tissue infection.  Archives of Surgery (2004 December) 139(12):1339-45.

Buckley, N.A., Isbister, G.K., et al.  Hyperbaric oxygen for carbon monoxide poisoning: A systematic review and critical analysis of the evidence.  Toxicology Review (2005) 24(2):75-92.

Juurlink, D.N., Buckley, N.A., et al.  Hyperbaric oxygen therapy for carbon monoxide poisoning. Cochrane Database Systematic Review (2005) (1):CD002041.

Bennett, M., Stanford, R., et al.  Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non-union.  Cochrane Database Systematic Review (2005) (1):CD004712.

Bennett, M., Kertesz, T., et al.  Hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss and tinnitus.  Cochrane Database Systematic Review (2005) (1):CD004739.

Bennett, M., Jepson, N., et al.  Hyperbaric oxygen therapy for acute coronary syndrome.  Cochrane Database Systematic Review (2005) (2):CD004818.

Bennett, M., Wasiak, J., et al.  Hyperbaric oxygen therapy for acute ischemic stroke.  Cochrane Database Systematic Review (2005) (3):CD004954.

Bennett, M., Feldmeier, J., et al.  Hyperbaric oxygen therapy for late radiation tissue injury.  Cochrane Database Systematic Review (2005) (3): CD005005.

Bennett, M., Best, T.M., et al.  Hyperbaric oxygenation therapy for delayed onset muscle soreness and closed soft tissue injury.  Cochrane Database Systematic Review (2005) (4):CD004713.

Bennett, M., Feldmeier, J., et al.  Hyperbaric oxygenation for tumor sensitization to radiotherapy. Cochrane Database Systematic Review (2005) (4):CD005007.

Van Voorhis, B.J., Greensmith, J.E., et al.  Hyperbaric oxygen and ovarian follicular stimulation for in vitro fertilization: A pilot study.  Fertility and Sterility (2005 January) 83(1):226-8.

Roeckl-Weidmann, I., Bennett, M., et al.  Systematic review of hyperbaric oxygen in the management of chronic wounds.  British Journal of Surgery (2005 January) 92(1):24-32.

Jallali, N., Withey, S., et al.  Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis.  American Journal of Surgery (2005 April) 189(4):462-6.

Bennett, M., Kertesz, T., et al.  Hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss and tinnitus: A systematic review of randomized controlled trials.  Journal of Laryngology and Otology (2005 October) 119(10):791-8.

Kao, L.W., and K.A. Nanagas.  Carbon monoxide poisoning.  Medical Clinics of North America (2005 November) 89(6):1161-94.

Carson, S., McDonagh, M., et al.  Hyperbaric oxygen therapy for stroke: A systematic review of the evidence.  Clinical Rehabilitation (2005 December) 19(8):819-33.

Alex, J., Laden, G., et al.  Pretreatment with hyperbaric oxygen and its effect on neuropsychometric dysfunction and systematic inflammatory response after cardiopulmonary bypass: A prospective randomized double-blind trial.  Journal of Thoracic and Cardiovascular Surgery (2005 December) 130(6):1623-30.

Al-Waili, N.S., and G.J. Butler.  Phototherapy and malignancy: Possible enhancement by iron administration and hyperbaric oxygen.  Medical Hypotheses (2006) 67(5):1148-58.

Rossignol, D.A., and L.W. Rossignol.  Hyperbaric oxygen therapy may improve symptoms in autistic children.  Medical Hypotheses (2006) 67(2):216-28.

Heys, S.D., Smith, I.C., et al.  A pilot study with long term follow up of hyperbaric oxygen pretreatment in patients with locally advanced breast cancer undergoing neo-adjuvant chemotherapy.  Undersea and Hyperbaric Medicine (2006 January-February) 33(1):33-43.

Vila, J.F., Barcarce, P.E., et al.  Improvement in motor and cognitive impairment after hyperbaric oxygen therapy in a selected group of patients with cerebrovascular disease: A prospective single-blind controlled trial.  Undersea and Hyperbaric Medicine (2006 September-October) 32(5):341-9.

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Rossignol, D.A., Rossignol, L.W., et al.  The effects of hyperbaric oxygen therapy on oxidative stress, inflammation, and symptoms in children with autism: an open-label pilot study.  BMC Pediatrics (2007) 7:36.

Rossignol, D.A.  Hyperbaric oxygen therapy might improve certain pathophysiological findings in autism.  Medical Hypotheses (2007) 68(6):1208-27.

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Delanian, S., and J.L. Lefaix.  Current management for late normal tissue injury: radiation-induced fibrosis and necrosis.  Seminars in Radiation Oncology (2007 April) 17(2):99-107.

Hampson, N.B., and J.M. Corman.  Rate of delivery of hyperbaric oxygen treatments does not affect response in soft tissue radionecrosis.  Undersea and Hyperbaric Medicine (2007 September-October) 34(5):329-34.

Ambiru, S., Furuyama, N., et al.  Hyperbaric oxygen therapy for the treatment of postoperative paralytic ileus and adhesive intestinal obstruction associated with abdominal surgery: experience with 626 patients.  Hepatogastroenterology (2007 October-November) 54(79):1925-9.

Christophi, C., Millar, I., et al.  Hyperbaric oxygen therapy for severe acute pancreatitis.  Journal of Gastroenterology and Hepatology (2007 November) 22(11):2042-6.

Myers, S.M., and C.P. Johnson.  Clinical Report: Management of children with autism spectrum disorders.  Pediatrics (2007 November) 120(5):1162-82.

Esposito, M., Grusovin, M.G., et al.  Interventions for replacing missing teeth; hyperbaric oxygen therapy for irradiated patients who require dental implants.  Cochrane Database System Review (2008) (1):CD003603.

Wolf, S.J., Lavonas, E.J., et al.  Clinical policy: critical issues in the management of adult patients presenting to the emergency department with acute carbon monoxide poisoning.  Annals of Emergency Medicine (2008 February) 51(2):138-52.

Hyperbaric Oxygen Pressurization (HBO-2).  Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2008 March) Medicine 2.01.04.

Policy History:

7/15/2011        Coverage revised only.  The following changes were made: 1) Systemic HBO2 may be considered medically necessary to treat soft-tissue radiation necrosis, including radiation enteritis, cystitis, or proctitis; 2) Review of diabetic wounds may occur after 30 systemic HBO2 treatments. 

3/1/2010          Revised/updated entire document, HBO2 may be considered medically necessary when clinical criteria is met

9/15/2008        Coverage revised, Rationale revised, References revised

8/15/2007        Revised/updated entire document

11/1/2000        Revised/updated entire document

3/2000             Revised/updated entire document

1/1996             Revised/updated entire document

5/1996             Medical policy number changed

5/1990             New medical document

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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