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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. Topical hyperbaric oxygen devices consist of an appliance to enclose the wound area (frequently an extremity) and a source of oxygen; conventional oxygen tanks may be used. The appliances may be disposable and may be used without supervision in the home by well-trained patients. Topical hyperbaric oxygen therapy has been investigated as a treatment of skin ulcerations due to diabetes, venous stasis, postsurgical infection, gangrenous lesions, decubitus ulcers, amputations, skin grafts, burns, or frostbite.

II. Systemic hyperbaric oxygen pressurization may be considered medically necessary in the treatment of the following conditions:

• Non-healing diabetic wounds of the lower extremities in patients who meet all of the following 3 criteria:

1. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes, and
2. Patient has a wound classified as Wagner grade 3 or higher*; and
3. Patient has no measurable signs of healing after 30 days of an adequate course of standard wound therapy

• Acute traumatic ischemia (e.g., crush injury, reperfusion injury, compartment syndrome)
• Decompression sickness
• Gas embolism, acute
• Cyanide poisoning, acute
• Soft-tissue radiation necrosis (e.g., radiation enteritis, cystitis, proctitis) and osteoradionecrosis
• Pre- and post-treatment for patients undergoing dental surgery (non-implant related) of an irradiated jaw
• Gas gangrene (i.e., clostridial myonecrosis)
• Profound anemia with exceptional blood loss only when blood transfusion is impossible or must be delayed, or when loss can be due to homolysis exsanguination
• Acute carbon monoxide poisoning
• Chronic refractory osteomyelitis

* The Wagner classification system of wounds is defined as follows:

III. Hyperbaric oxygen pressurization is considered investigational in the treatment of the following conditions:

• Compromised skin grafts or flaps
• Acute osteomyelitis, refractory to standard medical management
• Necrotizing soft-tissue infections
• Acute thermal burns
• Acute surgical and traumatic wounds
• Chronic wounds, other than those in patients with diabetes who meet the criteria specified in the medically necessary statement
• Spinal cord injury
• Traumatic brain injury
• Severe or refractory Crohn’s disease
• Brown recluse spider bites
• Bone grafts
• Carbon tetrachloride poisoning, acute
• Cerebrovascular disease, acute (thrombotic or embolic) or chronic
• Fracture healing
• Hydrogen sulfide poisoning
• Intra-abdominal and intracranial abscesses
• Lepromatous leprosy
• Meningitis
• Pseudomembranous colitis (antimicrobial agent-induced colitis)
• Radiation myelitis
• Sickle cell crisis and/or hematuria
• Demyelinating diseases, e.g., multiple sclerosis, amyotrophic lateral sclerosis
• Retinal artery insufficiency, acute
• Retinopathy, adjunct to scleral buckling procedures in patients with sickle cell peripheral retinopathy and retinal detachment
• Pyoderma gangrenosum
• Acute arterial peripheral insufficiency
• Acute coronary syndromes and as an adjunct to coronary interventions, including but not limited to percutaneous coronary interventions and cardiopulmonary bypass
• Idiopathic sudden sensorineural hearing loss
• Refractory mycoses: mucormycosis, actinomycosis, canidiobolus coronato
• Cerebral edema, acute
• Migraine
• Invitro fertilization
• Cerebral palsy
• Tumor sensitization for cancer treatments, including but not limited to, radiotherapy or chemotherapy
• Delayed onset muscle soreness
• Idiopathic femoral neck necrosis
• Chronic arm lymphedema following radiotherapy for cancer
• Radiation-induced injury in the head and neck
• Early treatment (beginning at completion of radiation therapy) to reduce adverse effects of radiation therapy
• Autism spectrum disorders
• Acute ischemic stroke
• Bell’s palsy

The following criteria taken from The Undersea and Hyperbaric Medical Society’s 1996 Hyperbaric Oxygen Therapy Committee may be used as a guideline for Systemic Hyperbaric Oxygen utilization:

Coverage:

• All medically necessary indications will be allowed for the first 20 treatments
• Coverage for additional benefits beyond this will only be allowed if there is written documentation in the patient's chart of wound healing and improvement (e.g., new tissue growth, shrinkage of ulcer, etc.)
• Reassessments and written documentation of continued wound healing must be done, at a minimum, every two (2) weeks
• Benefits will not be provided beyond a 3 month period

As specified in CPT code 99183, physician attendance and supervision of hyperbaric oxygen therapy is required.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

2/1997: Revision approved by MPAC. Thermal Burns, necrotic wounds to brown recluse spider bite and multiple sclerosis moved to investigational status. Required documentation after twenty (20) treatment limit and three (3) month maximum added.

5/2000: Revision approved by MPAC; soft tissue infections moved to investigational status and topical HBO2 added to investigational status. Undersea and Hyperbaric Medical Society's HBO therapy utilization guidelines added.

1/29/2001: HCPCS G0167 added covered codes

1/23/2002: Prior authorization deleted

2/7/2002: Investigational definition added

5/1/2002: Type of Service and Place of Service deleted

5/28/2002: Code Reference section updated, ICD-9 diagnosis code 784.5 should be 785.4, ICD-9 diagnosis code 383.20, 447.8, 454.0, 454.2, 459.89 added covered codes, ICD-9 diagnosis code 707.10, 707.11, 707.12, 707.13, 707.14, 707.15, 707.19, 707.8, 707.9 added non-covered codes, HCPCS A4575, A4619, E1390, E1391, E1399, E1405, E1406 added covered codes

9/20/2002: Policy reviewed, Hayes report number added

11/11/2002: HCPCS A4575 moved from covered codes to non-covered codes, Hayes report number deleted

3/10/2004: Code Reference section updated, invalid ICD-9 diagnosis code 929.99 deleted covered codes, ICD-9 diagnosis code 707.10, 707.11, 707.12, 707.13, 707.14, 707.15, 707.19, 707.8, 707.9 moved from non-covered codes to covered codes

11/5/2004: Code Reference section updated, ICD-9 procedure code 93.59 added non-covered codes, ICD-9 diagnosis code 006.5, 013.30, 013.31, 013.32, 013.33, 013.34, 013.35, 013.36, 030.0, 282.62, 320.0, 320.1, 320.2, 320.3, 320.7, 320.81, 320.82, 320.89, 320.9, 321.0, 321.1, 321.2, 321.3, 321.4, 321.8, 322.0, 322.1, 322.2, 322.9, 323.9, 324.0, 324.9, 326, 340, 361.00, 361.01, 361.02, 361.03, 361.04, 361.05, 361.06, 361.07, 361.2, 361.81, 361.89, 361.9, 362.60, 362.61, 362.62, 362.63, 362.64, 362.65, 362.66, 435.8, 436, 540.1, 556.2, 558.9, 569.5, 569.61, 572.0, 590.2, 599.7, 686.00, 686.01, 686.09, 776.5, 777.5, 800.00-800.99, 801.00-801.99, 802.0-802.9, 803.00-803.99, 804.00-804.99, 850.0-850.9, 851.00-851.99, 852.00-852.59, 853.00-853.19, 854.00-854.19, 940.0-940.9, 941.00-941.09, 941.10-941.19, 941.20-941.29, 941.30-941.39, 941.40-941.49, 941.50-941.59, 942.00-942.09, 942.10-942.19, 942.20-942.29, 942.30-942.39, 942.40-942.49, 942.50-942.59, 943.00-943.09, 943.10-943.19, 943.20-943.29, 943.30-943.39, 943.40-943.49, 943.50-943.59, 944.00-944.08, 944.10-944.18, 944.20-944.28, 944.30-944.38, 944.40-944.48, 944.50-944.58, 945.00-945.09, 945.10-945.19, 945.20-945.29, 945.30-945.39, 945.40-945.49, 945.50-945.59, 946.0-946.5, 947.0-947.9, 948.00-948.99, 949.0-949.5, 952.00-952.9, 959.01, 982.1, 985.1, 996.4, V12.59 deleted non-covered codes, HCPCS G0167 deletion date of 12/31/2004 added

9/19/2005: ICD-9 procedure code 93.59 moved from non-covered to covered codes

5/24/2006: G0167 deleted 12-31-2003. Code removed from the covered table

9/12/2006:  Coding updated.  CPT4/HCPCS 2006 revisions added to policy

11/29/2006: The following are now listed as investigational : amyotrophic lateral sclerosis; compromised skin grafts or flaps; chronic refractory osteomyelitis and acute osteomyelitis, refractory to standard medical management; delayed onset muscle soreness; acute cerebral edema; refractory mycoses: mucormycosis, actinomycosis, canidiobolus coronato; radiation necrosis (osteoradionecrosis and soft tissue radiation necrosis); acute arterial peripheral insufficiency; acute coronary syndromes and as an adjunct to coronary interventions, including but not limited to percutaneous coronary interventions and cardiopulmonary bypass; idiopathic sudden sensorneural hearing loss; migraine; in vitro fertilization; cerebral palsy; tumor sensitization for cancer treatments, including but not limited to, radiotherapy or chemotherapy. Removed "Radiation necrosis - utilization review is required after 60 treatments. Treatments are usually given daily for 90 to 120 minutes" from policy section

11/30/2006: Code Reference section updated. Deleted the following ICD-9 codes: 039.0-039.9, 090.0, 095.5, 111.0-111.9, 112.0, 112.1, 112.2, 112.3, 117.9, 348.5, 376.03, 383.20, 526.5, 526.89, 682.0-682.9, 686.00-686.09, 686.1, 686.8, 686.9, 730.00-730.29, 730.80-730.89, 767.8, 990, 996.52, and 996.79

3/19/2008: Soft tissue radiation necrosis and osteoradionecrosis changed from investigational to medically necessary. Added pre- and post treatment for dental surgery of an irradiated jaw may be considered medically necessary. Code reference section updated; ICD-9 codes 526.89, 909.2, and 909 added to covered table.

7/17/2008: Reviewed and approved by MPAC

9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied

12/1/2009: Policy Statement Section revised as follows: Hyperbaric oxygen pressurization is now not medically necessary for the treatment of acute carbon monoxide poisoning. Venous stasis ulcers and arterial insufficiency ulcers removed from medically necassary conditions. Additional criteria and Wagner classification system of wounds added to medically necessary criteria for non-healing diabetic wounds. Severe or refactory Crohn's disease added to investigational criteria. The Undersea and Hyperbaric Medical Society guideline updated with radiation necrosis information. Policy Exceptions Section revised to include FEP verbiage. Policy Coding Section revised as follows: ICD9 diagnosis codes 447.8, 454.0, 454.2, 459.89, 707.8, 707.9 removed from Covered Codes Table. ICD9 diagnosis code 986 moved to Non-Covered Codes Table, ICD9 Diagnosis Code 040.42 added to Covered Codes Table. HCPCS codes A4619, A4620, E0455, E1390, E1399, E1405, E1406 removed from Covered Codes Table.

09/09/2010:  Policy statement revised to indicate that HBO for acute carbon monoxide poisioning and chronic refractory osteomyelitis may be considered medically necessary. Added ICD-9 codes 730.00-730.19 to the Covered Codes table.  Moved ICD-9 code 986 from non-covered to covered.

11/10/2011:  Add the following as investigational indications for HBO:  acute surgical and traumatic wounds, idiopathic femoral neck necrosis, chronic arm lymphedema following radiotherapy for cancer, radiation-induced injury in the head and neck, early treatment (beginning at completion of radiation therapy) to reduce adverse effects of radiation therapy, and autism spectrum disorders.

09/27/2012:  Policy statement revised to add the following indications as investigational:  acute ischemic stroke, Bell’s palsy, and chronic wounds, other than those in patients with diabetes who meet the criteria specified in the medically necessary statement. Added reperfusion injury, compartment syndrome as examples of acute traumatic ischemia.

Blue Cross Blue Shield Association policy # 2.01.04

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. 

Covered Codes

This is not an all-inclusive list of non-covered procedure codes.

The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure.  

Non-Covered Codes 

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