Medical Policy


Subject:Hyperbaric Oxygen Therapy (Systemic/Topical)
Policy #:  MED.00005Current Effective Date:  01/14/2014
Status:ReviewedLast Review Date:  11/14/2013

Description/Scope

Systemic hyperbaric oxygen pressurization is a mode of medical treatment in which an individual is entirely enclosed in an air-tight chamber that is pressurized to 1.4 to 3.0 atmospheres absolute (atm abs or ATA) and is breathing 100% oxygen.  This increases oxygen levels in systemic circulation.  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 individual 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 hypothesized that the high concentrations of oxygen diffuse directly into the wound to increase the local cellular oxygen tension, which in turn promotes wound healing. 

Limb specific hyperbaric oxygen therapy is a technique by which a particular limb requiring treatment is placed in a miniature hyperbaric chamber and exposed to hyperbaric oxygen treatments.  The rest of the body is not exposed to this treatment.

Note:  For information regarding the use of hyperbaric oxygen therapy for the treatment of autism spectrum disorders, please see:

Position Statement

Medically Necessary:

Systemic hyperbaric oxygen pressurization is considered medically necessary in the treatment of any of the following conditions when performed in accordance with Undersea and Hyperbaric Medical Society (UHMS) guidelines:

Not Medically Necessary:

If the wound fails to show measurable signs of healing within 30 days of initiating and at each subsequent 30 day interval of systemic hyperbaric oxygen pressurization, continued therapy is considered not medically necessary.

Investigational and Not Medically Necessary:

Topical hyperbaric oxygen is considered investigational and not medically necessary in all cases.

Limb specific hyperbaric oxygen pressurization is considered investigational and not medically necessary in all cases.

Systemic hyperbaric oxygen pressurization is considered investigational and not medically necessary for all other conditions not previously listed, including but not limited to the treatment of tinnitus.

Rationale

Systemic Hyperbaric Oxygen

The position regarding systemic hyperbaric oxygen is based on guidelines published by the Undersea and Hyperbaric Medical Society (2008).  These guidelines provide recommendations for indications where hyperbaric oxygen therapy has been demonstrated to provide clinical benefits, and where there is adequate data to provide guidance regarding treatment duration, frequency and depth of pressurization.

Undersea and Hyperbaric Medical Society Guidelines:
The Undersea and Hyperbaric Medical Society's (UHMS) 2008 Hyperbaric Oxygen Therapy Committee suggests utilization of systemic hyperbaric oxygen therapy pressurization or "HBOT" guidelines as described below:

  1. Acute Thermal Burn Injury – Recommended for patients with serious burns, i.e., partial or full thickness burns covering greater than 20% of total body surface area or with involvement of the hands, face, feet or perineum. Treatment should begin as soon as possible following injury, often during initial resuscitation.  Treatments should be given for 90 minutes 3 times within the first 24 hours, and twice daily thereafter at 2.0-2.4 ATA (atmospheres absolute) of oxygen.  For large burns of 40% or greater, treatment for 10-14 days is recommended.  Treatment beyond 20-30 sessions is usually utilized to optimize grafting success.  It is rare to exceed 40-50 sessions.
  2. Air or Gas Embolism – Initial treatment should follow U.S. Navy Table #6, using 2.82 ATA of oxygen. Usual treatment involves 1-2 sessions, but may require 5-10.
  3. Arterial Insufficiencies – Treatment varies depending upon the severity of the condition and the type of chamber used.  In large multiplace chambers, treatments delivered between 2.0 and 2.5 ATA of oxygen for 90-120 minutes once or twice daily is standard.  In monoplace chambers, treatment at 2.0 ATA of oxygen for 90-120 minutes once or twice daily is standard.  Once the patient is stabilized, once daily treatment is recommended.  Details for specific conditions are below:
    1. Diabetic lower extremity wounds 
      • Patient with Type 1 or Type 2 Diabetes with lower extremity wound due to diabetes; and
      • Wegner grade III or higher wound severity; and
      • Patient has failed an adequate course of standard wound therapy (defined as 30 days of standard treatment including assessment and correction of vascular abnormalities, optimization of nutritional status and glucose control, debridement, moist wound dressing, off-loading, and treatment of infection; and
      • Re-evaluations at 30 days must show continued progress.
    2. Arterial insufficiency ulcers May benefit patients who have persistent hypoxia despite attempts at increasing blood flow or when wound failure continues despite maximum revascularization.
    3. Pressure ulcers Not recommended for the routine treatment of decubitus ulcers.  May be necessary for support of skin flaps and grafts showing evidence of ischemic failure, when the ulcer develops in the field of previous irradiated area for pelvic or perineal malignancies, or when progressive necrotizing soft tissue infection or refractory osteomyelitis is present.
    4. Venous stasis ulcers May be required to support skin grafting in patients with concomitant peripheral arterial occlusive disease and hypoxia not corrected by control of edema.
  4. Carbon Monoxide Poisoning - actual treatment pressure and time will vary, but compressions should be between 2.4 and 3.0 ATA of oxygen.  In patients with persistent neurologic dysfunction after the initial treatment, subsequent treatments may be performed within 6-8 hours and continued once or twice daily until there is no further improvement in cognitive functioning.  No more than 5 sessions should be needed to treat;
  5. Central Retinal Artery Occlusion (CRAO) – Patients presenting within 24 hours of symptoms should be considered for immediate HBOT.  Initiation of treatment should begin with delivery of 1 ATA of oxygen at the highest possible FiO2.  If there is no response within 5 minutes, then refer to HBOT at 2 ATA of oxygen as an adjunct to other interventions.  If vision improves, treat with 90 minutes of 2 ATA BID for a minimum of 3 days.  If vision does not improve within 5 minutes of 2 ATA of oxygen, press to a maximum of 2.8 ATA of oxygen, if no improvement occurs within 20 minutes at 2.8 ATA of oxygen, consider following U.S. Navy Table #6.  If vision does improve, continue treatment at effective pressure for 90 minutes BID.  Continue treatment until there is three consecutive days with no clinical improvement.  If the patient is a non-responder, initial treatment should be considered day 1 of treatment.
  6. Compartment syndrome – Treatment twice a day for 24-36 hours with oxygen breathing for 90 minutes each, or a single treatment a day for 120 minutes.  For residual complications after fasciotomy, treatments should be twice a day for 7-10 days, or when condition has stabilized such that no additional benefit is received.  Pressures should be 2.0 ATA in monoplace chambers and 2.4 ATA of oxygen in multiplace chambers.
  7. Compromised Skin Grafts and Flaps – Initial treatment is for 90-120 minutes at 2.0-2.5 ATA of oxygen.  Once the flap or graft is stable, once daily treatments may suffice.
  8. Crush Injuries – Two or more treatments a day with oxygen breathing for 90 minutes each, or a single treatment a day for 120 minutes.  Pressures should be 2.0 ATA of oxygen in monoplace chambers and 2.4 ATA of oxygen in multiplace chambers.
  9. Cyanide Poisoning - Patients with cyanide poisoning frequently present with simultaneous carbon monoxide poisoning.  Please see "Carbon Monoxide Poisoning" above for treatment recommendations.
  10. Decompression Sickness - treatment times vary, depending upon length of time elapsed between symptoms and initiation of treatment and between residual symptoms after initial treatment.  Complete resolution is most likely with early HBOT following U.S. Navy oxygen treatment tables with initial recompression to 2.82 ATA of oxygen.  Repeat treatments may be recommended until clinical stability is achieved, and should be administered step-wise as long as improvement occurs.  Complete resolution of symptoms or lack of improvement on two consecutive treatments establishes the end point.  No more than 5-10 treatments per individual is considered the norm.
  11. Gas Gangrene - Treatment should be administered for 90 minutes 3 times within the first 24 hours with 3.0 ATA of oxygen, and then twice daily for the next 2-5 days.  The decision to terminate treatment depends upon the patient's response to HBOT therapy.  If the patient remains toxic, the treatment needs to be extended.  No more than 10 sessions should be needed to treat;
  12. Intracranial Abscess (includes cerebral abscess, subdural empyema, and epidural empyema) - Treatment should be administered at 2.0-2.5 ATA of oxygen for 60-90 minutes once or twice daily, depending upon the severity of the condition.  
  13. Necrotizing Soft-Tissue Infections - HBOT treatments are given at a pressure of 2.0-2.5 ATA of oxygen and range from 90 minutes twice daily during the initial phase of therapy, until there is no longer evidence of progression and infection is considered under control.  If the diagnosis is in doubt and clostridial myositis and myonecrosis are still in the differential diagnosis, treatment at 2.8-3.0 ATA is recommended, using the gas-gangrene protocol of 3 treatments in the first 24 hours.  Once the patient's condition is stabilized, and prior to treatment cessation, treatment once daily may be instituted to assure relapse will not occur.
  14. Radiation Necrosis - 30-60 treatments for 90-120 minutes at 2.0-2.5 ATA of oxygen daily followed by debridement or resection, depending upon stage of condition.
  15. Refractory OsteomyelitisPatients with Cierny-Mader stage 1 and 2 should primarily be treated with antibiotics and limited surgical debridement.  HBOT is not recommended for these patients.  Patients with refractory stage 3B and 4B osteomyelitis should be considered candidates for HBOT.  Treatment should be given for 90-120 minutes at 2.3-2.5 ATA of oxygen once daily for 5 days per week.  Approximately 20-40 postoperative treatments should be delivered over a 4-6 week period.
  16. Severe AnemiaPulsed HBOT provides a way to clinically rectify oxygen debt in severe anemia when transfusion is not possible.  The patient initially can be treated with 2.0-3.0 ATA of oxygen with air breaks for up to 3-4 hours with surface interval titrated to avert symptoms of recurring oxygen debt.  Surface intervals between treatments may be lengthened, with the support of adjunctive hematinics, until hemoglobin concentrations are sufficient to allow adequate oxygen delivery at standard pressures.

In 2012 the American Academy of Neurology and the American Headache Society released guidelines regarding the use of complementary treatments for episodic migraine prevention in adults (Holland, 2012). These guidelines concluded that the data are conflicting or inadequate to support or refute hyperbaric oxygen for migraine prevention. 

The use of HBOT has been proposed for a wide range of conditions in addition to those addressed by the UHMS.  Most, including cerebral edema, spinal cord injury, and heat trauma have little in the way of clinical data to support HBOT therapy.  Further study of the impact of this treatment method for these conditions is warranted.

HBOT treatment for Tinnitus

Hyperbaric oxygen therapy (HBOT) has been proposed as a treatment for tinnitus that frequently accompanies sensorineural hearing loss. In a meta-analysis of the peer-reviewed literature, Bennett and colleagues (2005) evaluated the safety and efficacy of hyperbaric oxygen therapy (HBOT) for the treatment of individuals with idiopathic sudden sensorineural hearing loss (ISSHL) and tinnitus. In a single trial, 50 subjects were assessed for improvement in hearing and tinnitus after treatment with HBOT. Despite reporting improvement in hearing, the significance of any improvement in a subjective rating of tinnitus following HBOT could not be assessed due to poor reporting. The authors concluded that due to the small study population, methodological shortcomings, and the poor reporting, there is a lack of clinical evidence of a "beneficial effect" of HBOT on the chronic presentation of tinnitus. A randomized controlled trial of "high methodological rigor is justified to define those patients (if any) who can be expected to derive most benefit from HBOT" (Bennett, 2005).  A recent search of the literature identified only one recent small non-randomized retrospective controlled study involving 48 subjects with ISSHL who received standard care plus HBOT compared to 44 ISSHL subjects who received standard care (Ohno, 2010).  No significant differences were noted between groups with regard to mean hearing gain.  The authors conclude that "the effectiveness of secondary HBOT for ISSNHL patients in either subacute or chronic phase remains unproven, and thus, the decision to administer HBOT should be made with caution".

In October of 2011 the UHMS added idiopathic sudden sensorineural hearing loss to their list of indications.  However, unlike other indications recommended by UHMS, a rationale for this addition has not been made publicly available as of this review and is not on their website (www.UHMS.org).  Until a rationale is made available, we cannot fully evaluate this recommendation.

In 2012, the American Academy of Otolaryngology-Head and Neck Surgery published their clinical practice guideline for sudden hearing loss.  In this document they state; "The panel offered as options that clinicians may offer (1) corticosteroids as initial therapy to patients with ISSNHL [Idiopathic Sudden Sensoneural Hearing Loss] and (2) hyperbaric oxygen therapy within 3 months of diagnosis of ISSNHL."  This recommendation is based on aggregate evidence quality "Grade B, systematic review of RCTs with methodological limitations".  It is concluded that the evidence supporting the use of HBOT for the treatment of ISSHL is currently insufficient to draw reasonable conclusions about the efficacy of this service at this time.

Topical and Limb Specific Hyperbaric Oxygen Therapy

Due to their different methods of delivery, topical (including limb specific treatment) and systemic HBOT are distinct technologies such that the outcomes associated with systemic HBOT cannot be extrapolated to topical therapy.  Topical HBOT has been primarily investigated as a treatment of chronic wounds, but other conditions have also been proposed as possible indications.  There is currently insufficient published data from controlled trials to permit conclusions regarding topical HBOT.  Additionally, evidence in the form of data from in vitro studies of limb specific HBOT have failed to demonstrate that this treatment method increases tissue oxygen tension beyond the superficial dermis, a key factor in the efficacy of HBOT.  At this time the use of topic and limb specific HBOT are not supported by the available scientific evidence.

Background/Overview

Systemic Hyperbaric Oxygen Therapy

Systemic hyperbaric oxygen therapy (HBOT) involves the inhalation of pure oxygen gas while enclosed in a high-pressure chamber (defined as pressure greater than standard atmospheric pressure).  The therapy works by supersaturating the blood tissues with oxygen via increased atmospheric pressure as well as increased oxygen concentrations.  Studies have demonstrated that this therapy increases the available oxygen to the body by 10 to 20 times normal levels.  Treatment may be carried out in either a monoplace chamber pressurized with pure oxygen or in a larger, multiplace chamber pressurized with compressed air, in which case the individual receives pure oxygen by mask, head tent, or endotracheal tube.  The number and duration of treatment sessions and the atmospheric pressure during treatment varies depending on the specific condition being treated, the severity of the condition, and the procedures developed by individual hospitals and clinics.  These individual procedures vary widely and have made the evaluation of the efficacy of hyperbaric oxygen therapy difficult.  However, the medical specialty society which represents the physicians who specialize in this type of medical treatment, called the Undersea and Hyperbaric Medical Society (UHMS), created treatment recommendations for a wide variety of conditions for which HBOT has been proven to provide significant benefits.

Topical Hyperbaric Oxygen Therapy

Topical HBOT involves the delivery of pure oxygen directly to an open, moist wound at a pressure slightly higher than atmospheric pressure. Limb specific HBOT involves the use of a plastic container into which the limb to be treated is inserted and then sealed with pliable gaskets. The limb is then subjected to increased pressure and oxygen concentrations.  Much of the research on these forms of has focused on chronic wounds arising in individuals with diabetes– specifically foot wounds responsible for significant mortality and morbidity.  

Definitions

Anemia: A reduction in the number of circulating red blood cells or in the total hemoglobin content of the cells.

Atmospheres absolute (ATA): The combination (or the sum) of the atmospheric pressure and the hydrostatic pressure is called atmospheres absolute (ATA).  In other words, the ATA or atmospheres absolute is the total weight of the water and air above us.

Carbon monoxide poisoning: Toxicity that results from inhalation of small amounts of carbon monoxide (a poisonous gas) over a long period of time or from large amounts inhaled for a short time, which leads to decreased oxygen delivery to the body.

Chronic: Of a long duration; a disease that persists or progresses over time.

Compartmental syndrome: Any condition in which a structure such as a nerve or tendon is being constricted in a space and is no longer able to move freely in the compartment.

Decompression sickness: A condition that develops in divers subjected to rapid reduction of air pressure after coming to the surface following exposure to compressed air.

Gangrene: The death of tissue or bone, usually resulting from a deficient or absent blood supply.

Gas embolism: Obstruction of a blood vessel by a gas bubble.

Ischemia: A local and temporary deficiency of blood supply due to an obstruction of the circulation.

Limb specific hyperbaric oxygen: A therapy that involves sealing an individual's leg or arm into an airtight container and exposing that limb to pure oxygen greater than one atmosphere of pressure.

Mycosis: Any condition caused by a fungus.

Necrosis: A condition where cells or tissues are dead or dying.

Osteomyelitis: Inflammation of the bone due to infection.

Osteoradionecrosis: Death of bone following irradiation.

Prophylactic: Any agent or treatment that contributes to the prevention of infection or disease.

Pyoderma gangrenosum: A condition of the skin leading to open ulcers.Systemic hyperbaric oxygen: A therapy that involves sealing an individual inside a room or container, then exposing the individual to pure oxygen at greater than one atmosphere of pressure.

Thermal: Related to heat.

Tinnitus: A condition where an individual has the perception of sound in their head when no outside sound is present. Typically referred to as "ringing in the ears" or "head noise," but other forms of sound have been described such as hissing, roaring, pulsing, whooshing, chirping, whistling and clicking.

Topical hyperbaric oxygen: A therapy that involves sealing skin wounds under a plastic cover and then exposing the wound to pure oxygen at greater than one atmosphere of pressure; an alternate form of this therapy involves the application of a mist of water droplets to the wound that are saturated with dissolved oxygen.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. 

When services are Medically Necessary: 

CPT 
99183Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session
  
HCPCS 
C1300Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval
  
ICD-9 Procedure[For dates of service prior to 10/01/2014]
93.59Other immobilization, pressure and attention to wound (hyperbaric oxygenation of wound)
93.95Hyperbaric oxygenation
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
039.0-039.9Actinomycotic infections
040.0Gas gangrene
111.0-111.9Dermatomycosis, other and unspecified
112.0-112.3Candidiasis
117.7Zygomycosis (Phycomycosis, Mucormycosis, Conidiobolus infection)
117.9Other and unspecified mycoses
249.00-250.93Diabetes mellitus
285.1Acute posthemorrhagic anemia
324.0Intracranial abscess
362.31Central retinal artery occlusion
383.20-383.22Petrositis, osteomyelitis
443.89Other specified peripheral vascular diseases
443.9Peripheral vascular disease, unspecified (peripheral arterial insufficiency)
444.21Arterial embolism, upper extremity
444.22Arterial embolism, lower extremity
444.81Arterial embolism, iliac artery
459.9Unspecified circulatory system disorder
526.4Inflammatory conditions of jaw, osteomyelitis acute, chronic, suppurative
526.89Osteoradionecrosis of jaw
595.82 Irradiation cystitis
686.00-686.9Other local infections of skin and subcutaneous tissue
707.00-707.19Pressure ulcers, ulcer of lower limbs except pressure ulcers
707.20-707.25Pressure ulcer stages
707.8-707.9Chronic ulcer of other and unspecified sites
728.86Necrotizing fasciitis
728.9Unspecified disorder of muscle, ligament, and fascia
729.71-729.79Nontraumatic compartment syndrome
730.10-730.19Chronic osteomyelitis
785.4Gangrene  
870.0-897.7Open wounds
902.53Injury to iliac artery
903.01Injury to axillary artery
903.1-903.9Injury to blood vessels of upper extremity
904.0Injury to common femoral artery
904.1Injury to superficial femoral artery
904.41Injury to popliteal artery
904.51Injury to anterior tibial artery
904.53Injury to posterior tibial artery
904.6-904.9Injury to other blood vessels of lower extremity
906.0-906.1Late effect of open wound
906.4Late effect of crushing
909.2Late effect of radiation
925.1-929.9Crushing injury 
941.20-941.59Burns of face, head and neck, second and third degree
942.20-942.59Burns of trunk, second and third degree
943.20-943.59Burns of upper limb second and third degree
944.20-944.58Burns of wrist and hand, second and third degree
945.20-945.59Burns of lower limb, second and third degree
946.2-946.5Burns of multiple specified sites, second and third degree
948.00-948.99Burns classified according to extent of body surface involved, second and third degree
949.2-949.5Burn, unspecified second and third degree
958.0Air embolism, early complication of trauma
958.8Other early complications of trauma
958.90-958.99Traumatic compartment syndrome
986Toxic effect of carbon monoxide
987.7Toxic effect of hydrocyanic acid gas
989.0Toxic effect of hydrocyanic acid and cyanides
990Effects of radiation, unspecified
993.3Caisson disease (decompression sickness, bends)
996.52Mechanical complication due to graft of other tissue, not elsewhere classified (skin graft failure)
996.69Infection and inflammatory reaction due to other internal prosthetic device, implant, and graft
996.79Other complications due to other internal prosthetic device, implant, and graft
998.83Non-healing surgical wound
999.1Air embolism, complication of medical care
  
ICD-10 Procedure[For dates of service on or after10/01/2014]
5A05121Extracorporeal hyperbaric oxygenation, intermittent
5A05221Extracorporeal hyperbaric oxygenation, continuous
  
ICD-10 Diagnosis[For dates of service on or after10/01/2014]
A42.0-A42.9Actinomycosis
A48.0Gas gangrene
B36.0-B36.9Other superficial mycoses
B37.0-B37.9Candidiasis
B46.0-B46.9Zygomycosis
B48.0-B48.8Other mycoses, not elsewhere classified
B49Unspecified mycosis
D62Acute posthemorrhagic anemia
E08.00-E11.9Diabetes mellitus
E13.00-E13.9Other specified diabetes mellitus
G06.0Intracranial abscess and granuloma
H34.10-H34.13Central retinal artery occlusion
H70.201-H70.229Petrositis
I73.89Other specified peripheral vascular diseases
I73.9Peripheral vascular disease, unspecified
I74.2-I74.9Embolism and thrombosis of arteries (upper/lower extremities, iliac artery)
I96Gangrene, not elsewhere classified
I99.9Unspecified disorder of circulatory system
L08.0-L08.9Other local infections of skin and subcutaneous tissue
L88Pyoderma gangrenosum
L89.000-L89.95Pressure ulcer
L97.101-L97.929Non-pressure chronic ulcer of lower limb, not elsewhere classified
L98.411-L98.499Non-pressure chronic ulcer of skin, not elsewhere classified
M27.2Inflammatory conditions of jaws
M72.6Necrotizing fasciitis
M79.9Soft tissue disorder, unspecified
M79.A11-M79.A9Nontraumatic compartment syndrome
M86.30-M86.69Chronic osteomyelitis
M86.8X0-M86.8X9Other osteomyelitis
M86.9Osteomyelitis, unspecified
N30.40-N30.41Irradiation cystitis
S01.00XS-S01.95XSOpen wound of head [range with 7th character S]
S07.0XXA-S07.9XXSCrushing injury of head
S11.011S-S11.95XSOpen wound of neck [range with 7th character S]
S17.0XXA-S17.9XXSCrushing injury of neck
S21.001S-S21.95XSOpen wound of thorax [range with 7th character S]
S28.0XXA-S28.0XXSCrushed chest
S31.000S-S31.839SOpen wound of abdomen, lower back, pelvis and external genitals [range with 7th character S]
S38.001A-S38.1XXSCrushing injury of abdomen, lower back, pelvis and external genitals
S41.001S-S41.159SOpen wound of shoulder and upper arm [range with 7th character S]
S45.001A-S45.099SInjury of axillary artery
S45.801A-S45.999SUnspecified injury of other blood vessels at shoulder and upper arm level
S47.1XXA-S47.9XXSCrushing injury of shoulder and upper arm
S51.001S-S51.859SOpen wound of elbow and forearm [range with 7th character S]
T20.20XA-T20.29XSBurn of second degree of head, face, and neck
T20.30XA-T20.39XSBurn of third degree of head, face, and neck
T21.20XA-T21.29XSBurn of second degree of trunk
T21.30XA-T21.39XSBurn of third degree of trunk
T22.20XA-T22.299SBurn of second degree of shoulder and upper limb, except wrist and hand
T22.30XA-T22.399SBurn of third degree of shoulder and upper limb, expect wrist and hand
T23.201A-T23.299SBurn of second degree of wrist and hand
T23.301A-T23.399SBurn of third degree of wrist and hand
T24.201A-T24.299SBurn of second degree of lower limb, except ankle and foot
T24.301A-T24.399SBurn of third degree of lower limb, except ankle and foot
T25.211A-T25.299SBurn of second degree of ankle and foot
T25.311A-T25.399SBurn of third degree of ankle and foot
T31.0-T31.99Burns classified according to extent of body surface involved
T57.3X1A-T57.3X4SToxic effect of hydrogen cyanide
T58.01XA-T58.94XSToxic effect of carbon monoxide
T65.0X1A-T65.0X4SToxic effect of cyanides
T70.3XXA-T70.3XXSCaisson disease [decompression sickness]
T79.0XXA-T79.0XXSAir embolism (traumatic)
T79.A0XA-T79.A0XSCompartment syndrome, unspecified
T79.A11A-T79.A9XSTraumatic compartment syndrome
T86.820-T86.829Complications of skin graft (allograft)(autograft)

When services are Not Medically Necessary:

For the procedure codes listed above, when the situation listed in the Position Statement section as not medically necessary applies.

When services are Investigational and Not Medically Necessary:

For the procedure codes listed above, for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

When services are also Investigational and Not Medically Necessary: 

HCPCS 
A4575Topical hyperbaric oxygen chamber, disposable
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after10/01/2014]
 All diagnoses
References

Peer Reviewed Publications:

  1. Bennett M, Kertesz T, Yeung P. Hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss and tinnitus: a systemic review of randomized controlled trials. J Laryngol Otol. 2005; 119(10):791-798.
  2. Bevers RF, Bakker DJ, Kurth K. Hyperbaric oxygen treatment for haemorrhagic radiation cystitis. Lancet. 1995; 346(8978):803-805.
  3. Bill TJ, Hoard MA, Gampper TJ. Management of facial cutaneous defects, part II: applications of hyperbaric oxygen in otolaryngology head and neck surgery. Otolaryngol Clin North Am. 2001; 34(4):753-766.
  4. Capelli-Schellpfeffer M, Gerber GS. The use of hyperbaric oxygen in urology. J Urol. 1999; 162(3 Pt 1):647-654.
  5. Cesaro S, Brugiolo A, Faraci M, et al. Incidence and treatment of hemorrhagic cystitis in children given hematopoietic stem cell transplantation: a survey from the Italian association of pediatric hematology oncology-bone marrow transplantation group. Bone Marrow Transplant. 2003; 32(9):925-931.
  6. Chong KT, Hampson NB, Corman JM. Early hyperbaric oxygen therapy improves outcome for radiation-induced hemorrhagic cystitis. Urology. 2005; 65(4):649-653.
  7. Di Piero V, Cappagli M, Pastena L, et al. Cerebral effects of hyperbaric oxygen breathing: a CBF SPECT study on professional divers. Eur J Neurol. 2002; 9(4):419-421.
  8. Efrati S, Fishlev G, Bechor Y, et al. Hyperbaric oxygen induces late neuroplasticity in post stroke patients--randomized, prospective trial. PLoS One. 2013; 8(1):e53716.
  9. Faglia E, Favales F, Aldeghi A, et al. Adjunctive systemic hyperbaric oxygen therapy in treatment of severe prevalently ischemic diabetic foot ulcer. A randomized study. Diabetes Care. 1996; 19(12):1338-1343.
  10. Feldmeier JJ, Hampson NB. A systematic review of the literature reporting the application of hyperbaric oxygen prevention and treatment of delayed radiation injuries: an evidence based approach. Undersea Hyperb Med. 2002; 29(1):4-30.
  11. Fife CE, Buyukcakir C, Otto G, et al. Factors influencing the outcome of lower-extremity diabetic ulcers treated with hyperbaric oxygen therapy. Wound Repair Regen. 2007; 15(3):322-331.
  12. Freiberger JJ, Padilla-Burgos R, McGraw T, et al. What is the role of hyperbaric oxygen in the management of bisphosphonate-related osteonecrosis of the jaw: a randomized controlled trial of hyperbaric oxygen as an adjunct to surgery and antibiotics. J Oral Maxillofac Surg. 2012; 70(7):1573-1583.
  13. Hawkins M, Harrison J, Charters P. Severe carbon monoxide poisoning: outcome after hyperbaric oxygen therapy. Br J Anaesth. 2000; 84(5):584-586.
  14. Heng MC, Harker J, Csathy G, et al. Angiogenesis in necrotic ulcers treated with hyperbaric oxygen. Ostomy Wound Manage. 2000; 46(9):18-28, 30-32.
  15. Hulshof MC, Stark NM, van der Kleij A, et al. Hyperbaric oxygen therapy for cognitive disorders after irradiation of the brain. Strahlenther Onkol. 2002; 178(4):192-198.
  16. Igor S, Mirko T, Dalibor P, et al. Hyperbaric oxygenation accelerates prosthetic rehabilitation of lower limb amputees. Undersea Hyperb Med. 2013; 40(3):289-297.
  17. Kalani M, Jorneskog G, Naderi N, et al. Hyperbaric oxygen (HBO) therapy in treatment of diabetic foot ulcers. Long-term follow-up. J Diabetes Complications. 2002; 16(2):153-158.
  18. Kochanek PM, Jenkins LW, Edward-Dixon C, Clark RS. HBO: It's not ready for prime time for the treatment of acute central nervous system trauma. Crit Care Med. 2001; 29(4):906-908.
  19. Korhonen K. Hyperbaric oxygen therapy in acute necrotizing infections. With a special reference to the effects on tissue gas tensions. Ann Chir Gynaecol. 2000; 89 (Suppl) 214:7-36.
  20. Lacey DJ, Stolfi A, Pilati LE. Effects of hyperbaric oxygen on motor function in children with cerebral palsy. Ann Neurol. 2012; 72(5):695-703.
  21. Landau Z, Schattner A. Topical hyperbaric oxygen and low energy laser therapy for chronic diabetic foot ulcers resistant to conventional treatment. Yale J Biol Med. 2001; 74(2):95-100.
  22. Löndahl M, Katzman P, Nilsson A, Hammarlund C. Hyperbaric oxygen therapy facilitates healing of chronic foot ulcers in patients with diabetes. Diabetes Care. 2010; 33(5):998-1003.
  23. Muth CM, Shank ES. Gas embolism. N Engl J Med. 2000; 342(7):476-482.
  24. Myers RA. Hyperbaric oxygen therapy for trauma: crush injury, compartment syndrome, and other acute traumatic peripheral ischemias. Int Anesthesiol Clin. 2000; 38(1):139-151.
  25. Nuthall G, Seear M, Lepawsky M, et al. Hyperbaric oxygen therapy for cerebral palsy: two complications of treatment. Pediatrics. 2000; 106(6):E80.
  26. Ohno K, Noguchi Y, Kawashima Y, et al. Secondary hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss in the subacute and chronic phases. J Med Dent Sci. 2010; 57(2):127-132.
  27. Peng Z, Wang S, Huang X, Xiao P. Effect of hyperbaric oxygen therapy on patients with herpes zoster. Undersea Hyperb Med. 2012; 39(6):1083-1087.
  28. Rockswold SB, Rockswold GL, Vargo JM, et al. Effects of hyperbaric oxygenation therapy on cerebral metabolism and intracranial pressure in severely brain injured patients. J Neurosurg. 2001; 94(3):403-411.
  29. Rockswold SB, Rockswold GL, Zaun DA, et al. A prospective, randomized clinical trial to compare the effect of hyperbaric to normobaric hyperoxia on cerebral metabolism, intracranial pressure, and oxygen toxicity in severe traumatic brain injury. J Neurosurg. 2010; 112(5):1080-1094.
  30. Rusyniak DE, Kirk MA, May JD, et al. Hyperbaric oxygen therapy in acute ischemic stroke; results of the Hyperbaric Oxygen in Acute Ischemia Stroke Trial Pilot Study. Stroke. 2003; 34(2):571-574.
  31. Sampanthavivat M, Singkhwa W, Chaiyakul T, et al. Hyperbaric oxygen in the treatment of childhood autism: a randomised controlled trial. Diving Hyperb Med. 2012; 42(3):128-133.
  32. Scheinkestel CD, Bailey M, Myles PS, et al. Hyperbaric or normobaric oxygen for acute carbon monoxide poisoning: a randomized controlled clinical trial. Med J Aust. 1999; 170(5):203-210.
  33. Schoen PJ, Raghoebar GM, Bouma J, et al. Rehabilitation of oral function in head and neck cancer patients after radiotherapy with implant-retained dentures: effects of hyperbaric oxygen therapy. Oral Oncol. 2007; 43(4):379-388.
  34. Sen CK, Khanna S, Gordillo G, et al. Oxygen, oxidants, and antioxidants in wound healing: an emerging paradigm. Ann N Y Acad Sci. 2002; 957:239-249.
  35. Shank ES, Muth CM. Decompression illness, iatrogenic gas embolism, and carbon monoxide poisoning: the role of hyperbaric oxygen therapy. Int Anesthesiol Clin. 2000; 38(1):111-138.
  36. Steele J, Zutshi D, Bradley WG. Negative results of a phase II study of hyperbaric oxygen therapy for amyotrophic lateral sclerosis. Amyotroph Lateral Scler. 2007; 8(5):274-275.
  37. Van Meter KW.  A systematic review of the application of hyperbaric oxygen in the treatment of severe anemia: an evidence-based approach. Undersea Hyperb Med. 2005; 32(1):61-83.
  38. Weaver LK, Hopkins RO, Chan K, et al. Hyperbaric oxygen for acute carbon monoxide poisoning. N Engl J Med. 2002; 347(14):1057-1067.
  39. Wolf G, Cifu D, Baugh L, et al. The effect of hyperbaric oxygen on symptoms after mild traumatic brain injury. J Neurotrauma. 2012; 29(17):2606-2612.
  40. Wood Z. Hyperbaric oxygen in the management of chronic wounds. Br J Nurs. 2002; 11(16 Suppl):S16, S18-19, S22-24.
  41. Yogaratnam JZ, Laden G, Guvendik L, et al. Hyperbaric oxygen preconditioning improves myocardial function, reduces length of intensive care stay, and limits complications post coronary artery bypass graft surgery. Cardiovasc Revasc Med. 2010; 11(1):8-19.

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. Agency for Healthcare Research and Quality. Hyperbaric Oxygen Therapy in the Treatment of Hypoxic Wounds and Diabetic Wounds of the Lower Extremities. Technology Assessment 2001.
  2. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Management of Adult Patients Presenting to the Emergency Department with Carbon Monoxide Poisoning, Wolf SJ, Lavonas EJ, Sloan EP, Jagoda AS. Clinical policy: Critical issues in the management of adult patients presenting to the emergency department with acute carbon monoxide poisoning. Ann Emerg Med. 2008; 51(2):138-152.
  3. Bennett M, Best TM, Babul S, et al. Hyperbaric oxygen therapy for delayed onset muscle soreness and closed soft tissue injury. Cochrane Database Syst Rev. 2005;(4):CD004713.
  4. Bennett MH, Feldmeier J, Hampson N, et al. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database Syst Rev. 2005;(3):CD005005.
  5. Bennett M, Feldmeier J, Smee R, Milross C. Hyperbaric oxygenation for tumour sensitisation to radiotherapy. Cochrane Database Syst Rev. 2005;(4):CD005007.
  6. Bennett MH, French C, Schnabel A, et al. Normobaric and hyperbaric oxygen therapy for migraine and cluster headache. Cochrane Database Syst Rev. 2008;(3):CD005219.
  7. Bennett M, Heard R. Hyperbaric oxygen therapy for multiple sclerosis. Cochrane Database Syst Rev. 2004; (1):CD003057.
  8. Bennett MH, Feldmeier J, Hampson N, Smee R, Milross C. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database Syst Rev. 2012, Issue 5. Art. No.: CD005005.
  9. Bennett MH, Feldmeier J, Smee R, Milross C. Hyperbaric oxygenation for tumour sensitisation to radiotherapy. Cochrane Database Syst Rev. 2012, Issue 4. Art. No.: CD005007.
  10. Bennett MH, Kertesz T, Yeung P. Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus. Cochrane Database Syst Rev. 2007;(1):CD004739.
  11. Bennett MH, Lehm JP, Mitchell SJ, Wasiak J. Recompression and adjunctive therapy for decompression illness. Cochrane Database Syst Rev. 2012, Issue 5. Art. No.: CD005277.
  12. Bennett MH, Lehm JP, Jepson N. Hyperbaric oxygen therapy for acute coronary syndrome. Cochrane Database Syst Rev. 2011;(8):CD004818.
  13. Bennett MH, Stanford R, Turner R. Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non-union. Cochrane Database Syst Rev. 2005;(1):CD004712.
  14. Bennett MH, Trytko B, Jonker B. Hyperbaric oxygen therapy for the adjunctive treatment of traumatic brain injury. Cochrane Database Syst Rev. 2004;(4):CD004609.
  15. Bennett MH, Wasiak J, Schnabel A, et al. Hyperbaric oxygen therapy for acute ischaemic stroke. Cochrane Database Syst Rev. 2005;(3):CD004954.
  16. Buckley NA, Juurlink DN, Isbister G, et al. Hyperbaric oxygen for carbon monoxide poisoning. Cochrane Database Syst Rev. 2011;(4):CD002041.
  17. Centers for Medicare and Medicaid Services. National Coverage Determinations. Available at:  http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on September 17, 2013.
    •  Hyperbaric Oxygen Therapy. NCD #20.29. Effective April 1, 2003.
  18. Denton AS, Maher J. Interventions for the physical aspects of sexual dysfunction in women following pelvic radiotherapy. Cochrane Database Syst Rev. 2003, Issue 1. Art. No.: CD003750.
  19. Esposito M, Grusovin MG, Patel S, et al. Interventions for replacing missing teeth: hyperbaric oxygen therapy for irradiated patients who require dental implants. Cochrane Database Syst Rev. 2008;(1):CD003603.
  20. Holland NJ, Bernstein JM, Hamilton JW. Hyperbaric oxygen therapy for Bell's palsy. Cochrane Database Syst Rev.  2012, Issue 2. Art. No.: CD007288.
  21. Holland S, Silberstein SD, Freitag F, et al.; Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012; 78(17):1346-353.
  22. Kranke P, Bennett MH, Martyn-St James M, Schnabel A, Debus SE. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev. 2012, Issue 4. Art. No.: CD004123.
  23. National Institutes of Health Consensus Development Conference Statement: Oral Complications of Cancer Therapies: Diagnosis, Prevention, and Treatment. 1989 (update 1995). Bethesda, MD.
  24. Phillips JS, Jones SE. Hyperbaric oxygen as an adjuvant treatment for malignant otitis externa. Cochrane Database Syst Rev. 2005;(2):CD004617.
  25. Stachler RJ, Chandrasekhar SS, Archer SM, et al; American Academy of Otolaryngology-Head and Neck Surgery. Clinical practice guideline: sudden hearing loss. Otolaryngol Head Neck Surg. 2012; 146(3 Suppl):S1-35.
  26. Undersea and Hyperbaric Medical Society. Bennett M, Heard R. UHMS position statement: treatment of multiple sclerosis with hyperbaric oxygen therapy. Undersea Hyperb Med. 2001; 28(3):117-122.
  27. Undersea and Hyperbaric Medical Society. Feldmeier JJ, Hopf HW, Warriner RA 3rd, et al. UHMS position statement: topical oxygen for chronic wounds. Undersea Hyperb Med. 2005; 32(3):157-168.
  28. Undersea and Hyperbaric Medical Society.  Hyperbaric Oxygen Therapy Indications (2009). Available at: http://www.uhms.org/Default.aspx?tabid=270. Accessed on September 17, 2013.
  29. United States Navy Dive Manual, Revision 6. Treatment table 6. Page 20-41. Available at:  http://www.supsalv.org/00c3_publications.asp. Accessed on September 17, 2013. 
  30. Villanueva E, Bennett MH, Wasiak J, Lehm JP. Hyperbaric oxygen therapy for thermal burns. Cochrane Database Syst Rev. 2004;(3):CD004727.
  31. Xiao Y, Wang J, Jiang S, Luo H. Hyperbaric oxygen therapy for vascular dementia. Cochrane Database Syst Rev. 2012, Issue 7. Art. No.: CD009425.
Web Sites for Additional Information
  1. National Library of Medicine. Medical Encyclopedia. Hyperbaric oxygen therapy. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/002375.htm.  Accessed on September 17, 2013.
Index

Air Embolism
Extreme Chamber Therapy
Extremity Oxygen Therapy
Osteomyelitis, Acute and Chronic
Osteoradionecrosis
Tinnitus

Document History
StatusDateAction
Reviewed11/14/2013Medical Policy & Technology Assessment Committee (MPTAC) review.  No change to the position statement.  Updated Rationale and Reference sections. 
Reviewed11/08/2012MPTAC review.  No change to the position statement.  Updated Rationale and Reference sections.  Updated Coding section with 01/01/2013 CPT descriptor change.
Reviewed11/17/2011MPTAC review.  No change to the position statement.  Updated reference section.
Revised11/18/2010MPTAC review. Moved HBOT treatment of tinnitus to investigational and not medically necessary section from MED.00073 Treatment of Tinnitus which was archived.  Updated Rationale and Reference sections.
Reviewed02/25/2010MPTAC review. No change to position statement.  Updated Reference section.
 10/01/2009Updated Coding section with 10/01/2009 ICD-9 changes.
Revised02/26/2009MPTAC review. Clarified use in chronic wounds to require reassessment at each subsequent 30 day interval.  Added central retina artery occlusion (CRAO) as a medically necessary indication.  Added central retina artery occlusion (CRAO) as a medically necessary indication. Changed "profound" anemia to "severe" anemia in medically necessary section.  Deleted "acute" osteomyelitis and cerebral edema from the medically necessary section.  Revised medically necessary statement regarding radiation necrosis to read "delayed radiation injury". Deleted list of I/E and NMN indications, leaving it to read I/E and NMN "for all indications".  Updated Rationale, Background, Coding and Reference sections.
Revised08/28/2008MPTAC review. Added radiation cystitis as medically necessary when used as an adjuvant therapy. Added tinnitus to investigational and not medically necessary section. Deleted "intracranial abscess" from investigational and not medically necessary section. Revised Rationale section.  Updated Coding section with 10/01/2008 ICD-9 changes.
Reviewed05/15/2008MPTAC review. No change to position statement.  Updated Coding and Reference sections.
 02/21/2008The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed05/17/2007MPTAC review. No change to position statement. Updated Coding and Reference sections.
Revised06/08/2006MPTAC review.  Moved radiation cystitis from Investigational and Not Medically Necessary to Medically Necessary.  Updated Coding and Reference sections.

 

 

11/22/2005Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised07/14/2005MPTAC review.  Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations
Last Review DateDocument Number

Title

 

Anthem, Inc.

 

04/28/2005MED.00005Hyperbaric Oxygen Therapy (Systemic/Topical)
WellPoint Health Networks, Inc.04/28/20052.01.01Hyperbaric Oxygen Therapy:  Systemic
 09/23/20042.02.01Oxygen Therapy (Low Pressure) for Wound Care