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DESCRIPTIONHyperbaric oxygen therapy (HBO2) is a technique of delivering higher pressures of oxygen to the tissues. Two methods of administration are available. In systemic or large chamber hyperbaric oxygen, the patient is entirely enclosed in a pressure chamber and breathes oxygen at a pressure greater than one atmosphere (the pressure of O2 at sea level). Thus this technique relies on the systemic circulation to deliver highly oxygenated blood to the target site, typically a wound. In addition, systemic hyperbaric oxygen therapy can be used to treat systemic illness such as air or gas embolism, carbon monoxide poisoning, clostridial gas gangrene, etc. Treatment may be carried out either in a monoplace chamber pressurized with pure oxygen or in a larger, multiplace chamber pressurized with compressed air, in which case the patient receives pure oxygen by mask, head tent, or endotracheal tube.
Topical hyperbaric oxygen therapy is a technique of delivering 100% oxygen directly to an open, moist wound at a pressure slightly higher than atmospheric pressure. It is 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.
POLICYI. Topical hyperbaric oxygen therapy is considered investigational.
II. Systemic hyperbaric oxygen pressurization may be considered medically necessary in the treatment of the following conditions:
* The Wagner classification system of wounds is defined as follows:
III. Hyperbaric oxygen pressurization is considered investigational in the treatment of the following conditions:
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:
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
As specified in CPT code 99183, physician attendance and supervision of hyperbaric oxygen therapy is required.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY3/1993: Approved by Medical Policy Advisory Committee (MPAC)
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.
11/15/2013: Policy statement revised to add the following indications as investigational: Bisphosphonate-related osteonecrosis of the jaw, motor dysfunction associated with stroke, herpes zoster, and vascular dementia.
12/31/2014: Added the following new 2015 CPT code(s) to the Code Reference section: G0277.
05/04/2015: Investigational policy statement for hyperbaric oxygen pressurization revised to change "Acute osteomyelitis, refractory to standard medical management" to "Acute osteomyelitis."
08/27/2015: Code Reference section updated to add ICD-10 codes. Changed ICD-9 diagnosis code range 730.00 – 730.19 to 730.10 – 730.19 for chronic osteomyelitis.
09/29/2015: Code Reference section updated to add ICD-9 diagnosis codes 558.1 and 595.82.
11/23/2015: Code Reference section updated to include the "D" suffix codes for subsequent encounters for the applicable code ranges.
04/26/2016: Policy Guidelines updated to add medically necessary and investigative definitions.
06/06/2016: Policy number added.
SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policy # 2.01.04
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.