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MEDICAL POLICY

SUBJECT: HYPERBARIC OXYGEN THERAPY EFFECTIVE DATE: 11/19/99
(HBOT) REVISED DATE: 04/17/02, 04/24/03, 05/19/04, 07/21/05,
09/21/06, 07/19/07, 06/19/08, 09/18/08,
09/17/09, 02/17/11, 04/19/12, 03/21/13,
POLICY NUMBER: 2.01.07 03/20/14, 03/19/15, 03/17/16
CATEGORY: Technology Assessment PAGE: 1 OF: 14
• If a product excludes coverage for a service, it is not covered, and medical policy criteria do not apply.
• If a commercial product, including an Essential Plan product, covers a specific service, medical policy criteria
apply to the benefit.
• If a Medicare product covers a specific service, and there is no national or local Medicare coverage decision for
the service, medical policy criteria apply to the benefit.
POLICY STATEMENT:
I. Topical hyperbaric oxygen therapy
Based on our criteria and review of the peer-reviewed literature, topical hyperbaric oxygen therapy has not been
medically proven to be effective and is considered investigational.
II. Systemic hyperbaric oxygen therapy
A. Based on our criteria and review of the peer-reviewed literature, systemic hyperbaric oxygen therapy in a
pressurized chamber has been medically proven to be effective and therefore medically appropriate for the
following indications (refer to Policy Guideline V for condition specific recommendations):
1. Carbon monoxide poisoning, acute;
2. Cerebral edema, acute;
3. Crush injury with acute traumatic ischemia;
4. Cyanide poisoning, acute;
5. Decompression sickness;
6. Diabetic wounds, non-healing, of the lower extremities in patients who:
a. have type I or type II diabetes and a lower extremity wound due to diabetes; and
b. have a wound classified as Wagner grade 3 or higher (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: gangrene of the forefoot;
Grade 5: gangrene of the entire foot); and
c. have no measurable signs of healing after 30 days of an adequate course of standard wound therapy;
which includes the following:
i. assessment of vascular status and correction of any vascular problems in the affected limb if
possible;
ii. optimization of nutritional status;
iii. optimization of glucose control;
iv. debridement by any means to remove devitalized tissue;
v. maintenance of clean, moist bed of granulation tissue with appropriate moist dressings;
vi. appropriate off-loading; and
vii. treatment to resolve any infection that might be present.
7. Gas embolism, acute;
8. Gas/wet gangrene (e.g., clostridial myonecrosis);
9. Osteomyelitis, acute, refractory (has not responded to standard medical and surgical management
techniques);
10. Osteomyelitis, chronic refractory (has persisted for at least 6 weeks or recurred after appropriate
interventions - surgical debridement and at least one appropriate course of parenteral antibiotics - have been
performed);
11. Pre- and post-treatment for patients undergoing dental surgery (non-implant related) of an irradiated jaw;
12. Profound anemia with exceptional blood loss: only when blood transfusion is impossible or must be delayed;
13. Radiation necrosis (osteoradionecrosis and soft tissue radiation necrosis, e.g., radiation enteritis, cystitis,
Proprietary Information of Excellus Health Plan, Inc.
A nonprofit independent licensee of the BlueCross BlueShield Association

Inflammatory bowel disease (Crohn’s disease. 07/21/05. Intra-abdominal and intracranial abscesses. . acute (thrombotic or embolic) or chronic. Retinopathy. 28. 19. Fracture healing. In vitro fertilization. 04/24/03. Brown recluse spider bites. 41. 32. Compromised skin grafts or flaps. 22. 18. 9. canidiobolus coronato. Complex regional pain syndrome. 4. 42. Breast cancer. 09/21/06. 34. 04/19/12. 23. Retinal detachment. Retinal artery insufficiency. for the purpose of tumor sensitization. Pseudomembranous colitis (antimicrobial agent-induced colitis).g. 06/19/08. 09/18/08.SUBJECT: HYPERBARIC OXYGEN THERAPY EFFECTIVE DATE: 11/19/99 (HBOT) REVISED DATE: 04/17/02. acute. Arterial peripheral insufficiency. Meningitis. Fibromyalgia syndrome. Based on our criteria and review of the peer-reviewed literature. idiopathic sudden sensorineural hearing loss) and tinnitus. Hydrogen sulfide poisoning. 13. 36. 2. 25. 30. as pretreatment.07 03/20/14. 7. 03/21/13. systemic hyperbaric oxygen therapy in a pressurized chamber has not been medically proven to be effective and is considered investigational for all other indications including. Autism spectrum disorders. Muscle soreness. Soft tissue injury. actinomycosis. Cardiopulmonary bypass. 40. Head injury. traumatic (including traumatic brain injury). Acute ischemic stroke. Refractory mycosis: mucormycosis. Radiation myelitis. the following indications: 1. Migraine. but not limited to. 29. Bell’s palsy. Proprietary Information of Excellus Health Plan. Frostbite. 33. with tissue necrosis (Meleney ulcer) and refractory bacteroides. 10. 14. 26. 09/17/09. 16. Amyotrophic Lateral Sclerosis. ulcerative colitis). 20. Soft tissue infections due to mixed aerobic and anaerobic organisms. 27. or 15. Multiple sclerosis. 8. B. Sickle cell crisis and/or hematuria. 14. 31. 37. 3. Cerebral palsy. 39. 21. 24. Bone grafts. Carbon tetrachloride poisoning. 15. 05/19/04. non-healing wounds. 38. Prevention of coronary restenosis. 6. 17. 35. Malignant otitis externa. 07/19/07. Lepromatous leprosy. Interstitial cystitis. POLICY NUMBER: 2. Inc. Myocardial infarction and acute coronary syndrome (acute myocardial infarction and unstable angina). Pyoderma gangrenosum. 02/17/11. 11.. locally advanced. adjunct to scleral buckling procedures in patients with sickle cell peripheral retinopathy. 12.01. 03/19/15. Cerebrovascular disease. acute. Radiation therapy. Hearing loss (e. acute. as pretreatment for patients undergoing chemotherapy. 5. 03/17/16 CATEGORY: Technology Assessment PAGE: 2 OF: 14 proctitis). delayed onset. Chronic.

documentation of attendance. 03/21/13. Thermal burns.0 When blood transfusion is Treatments of up to 3 or 4 hours. The following information must be documented. descent time. HBOT treatments should be discontinued when either the patient heals. and decrease in pain. POLICY NUMBER: 2. B. Effect of treatment upon established HBOT goals. 04/24/03. improvement in exudates. and once daily for 2 days is threatened and tissue oxygen tension is below 30 mmHg. Below are specific recommendations on the utilization of HBOT based upon published. SUBJECT: HYPERBARIC OXYGEN THERAPY EFFECTIVE DATE: 11/19/99 (HBOT) REVISED DATE: 04/17/02. C. oxygen dose.0 Within 6 hours of patient One treatment. Spinal cord injury. HBOT session records describing physical findings and treatment rendered (including ascent time. 03/17/16 CATEGORY: Technology Assessment PAGE: 3 OF: 14 43.07 03/20/14. D. Proprietary Information of Excellus Health Plan.0-3. II. peer-reviewed literature. Condition Pressure Patient Selection Criteria Duration. Frequency and/or Utilization (ATA*) Number of Treatments review Anemia. or fails to improve. acute ATA sodium nitrite. 09/17/09. Carbon 2. Continued treatment with HBOT is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. E. can continue with taper of time and frequency until red blood cells have been satisfactorily replaced by patient regeneration or the patient can undergo transfusion. HBOT should not be a replacement for successful standard therapeutic measures. is unable to tolerate treatment. if patient has After 5 monoxide ATA removal from the carbon persistent neurologic dysfunction treatments poisoning.0 As an adjunct to infusion of One treatment of 120 minutes. 05/19/04. 07/21/05.01. 09/21/06. Established HBOT goals. Inc. total compression time. as applicable. treatment can occur within 6-8 hours and can be continued once or twice daily until there is no additional improvement in cognitive function. The history should list prior treatments including antibiotic therapy and surgical interventions.5-3. Crush injury 2.5-3. 03/19/15. Current adjunctive treatment that includes treatment-type and its effectiveness. III.5 hours treatments per day After 20 ATA therapeutic measures when for 2 days. then twice a day for 2 treatments loss of function. Treatment delayed. acute. 06/19/08. 44. Initial assessment and medical history detailing the condition requiring HBOT and a physical exam. Daily ATA impossible or must be three to four times a day. POLICY GUIDELINES: I. to the specific medical condition: A. poisoning. 04/19/12. 07/19/07. Cyanide 2. 09/18/08. increased and/or improved color of granulation.4 In conjunction with standard Three 1. and a recording of events). severe 2. 02/17/11. limb or life days. pressurization level. Documentation in the medical record should support the specific condition being treated with HBOT and the medical necessity of such treatment. Measurable signs of healing include shrinkage of the wound in diameter and/or depth.0-2. IV. acute monoxide contaminated after the initial treatment further environment. .

ATA least 6 weeks or recurred and can be continued for 4-6 weeks sessions refractory after surgical debridement for patients who respond to initial and at least one appropriate treatment with antibiotics.14 hours After 10 sickness ATA blood in volumes sufficient duration. treatments can be given. If patients are not responding they are considered stage II and receive more extensive surgical debridement then 10 additional treatments. Osteoradionecr. Diabetic 2.5 Infection persisted for at Daily treatment for 90-120 minutes After 30-40 chronic. debridement and hyperbaric oxygen biotics have been performed. Proprietary Information of Excellus Health Plan. If response treatments postoperative management is adequate. generally no more than 5-10 treatments. 2.5 As adjunctive treatment in 30 treatments followed by only After 10-30 osis ATA the preoperative and minor bony debridement. treatments pressure with the function of an organ treatment continues until no mixed and results in ischemia to the additional improvement is seen. the first 24 hours and then two treatments myonecrosis) tissue gas visualization on x. Gas embolism.0 Gas bubbles in the tissue or One treatment of 1.. High to Gases in the vasculature Treatment is typically 1-2 treatments After 10 acute low sufficient enough to interfere but occasionally up to 5-10. 03/17/16 CATEGORY: Technology Assessment PAGE: 4 OF: 14 Condition Pressure Patient Selection Criteria Duration. severe and sudden pain. 07/21/05. 07/19/07.0-2. if patients has residual treatments enough to interfere with the defects after the initial the initial function of an organ or cause treatment they should receive alteration in sensation. surgical course of parenteral anti. Stage III patients receive 30 treatments followed by mandibular segmental resection and then 10 additional treatments. 03/19/15.0-5. 09/21/06. POLICY NUMBER: 2.5.01. Gas gangrene 3. and edema.0 ATA Positive gram stained smear Three 90-minute treatments during After 10 (e. 06/19/08.g. 04/19/12.0-2. therapy. may last for 30-40 treatments. Frequency and/or Utilization (ATA*) Number of Treatments review Decompression 2. gases affected areas. 09/18/08.0-3. ATA and failure of standard week are performed in conjunction treatments healing wound therapy for at least 30 with continuing standard wound consecutive days. additional treatments until clinical stability is achieved.SUBJECT: HYPERBARIC OXYGEN THERAPY EFFECTIVE DATE: 11/19/99 (HBOT) REVISED DATE: 04/17/02. 5 days per After 20 wounds. 2. skin changes. Inc. care. an additional 10 of the patient. .0 Wagner grade 3 or higher 90 minute treatments. non. 03/21/13. 04/24/03. days. 09/17/09. 05/19/04. Osteomyelitis. clostridial or culture from tissue fluids. 02/17/11.07 03/20/14.treatments per day for the next 2-5 ray.

05/19/04. then treatments necrosis mortality are expected to be once daily. Inc. The CMS criteria states: A.07 03/20/14.. B.. The physician supervision requirement is presumed to be met when services are performed on the hospital premises (i. 09/18/08. mucormycosis) antibiotics and surgical treatment. 06/19/08. *1 ATA (atmospheres absolute) = pressure of 760 mmHg. 03/21/13.0-2. Information relating to the frequency of treatment and other treatment specifics can also be found at the web site of the Undersea & Hyperbaric Medical Society (UHMS) [https://www. POLICY NUMBER: 2. treatment can continue for treatments actinomycosis.SUBJECT: HYPERBARIC OXYGEN THERAPY EFFECTIVE DATE: 11/19/99 (HBOT) REVISED DATE: 04/17/02. VI.5 Evidence of overt fracture or Initial treatment for stage I patients After 10-30 osis.html].5 In conjunction with standard One to two times daily for 90-120 After 10-30 mycosis (e. 14. . If response is treatments adequate 10 additional treatments can be provided. in all instances. high despite aggressive standard treatment. 760 torr. 03/17/16 CATEGORY: Technology Assessment PAGE: 5 OF: 14 Condition Pressure Patient Selection Criteria Duration. Frequency and/or Utilization (ATA*) Number of Treatments review Osteoradionecr.uhms.5 Adjunctive therapy only in Twice daily for 90 to 120 minutes After 30 infection with ATA patients where morbidity and until condition is stabilized. 03/19/15. 2. 04/24/03.0-2. Physicians supervising hyperbaric oxygen therapy should be certified in Undersea and Hyperbaric Medicine by the American Board of Emergency Medicine (ABEM) or the American Board of Preventive Medicine (APBM) or the American Osteopathic Conjoint Committee of Undersea and Hyperbaric Medicine (AOCUHM).e. Proprietary Information of Excellus Health Plan.org/resources/hbo-indications. mandibular ATA bony resorption. It is recommended the Centers for Medicare and Medicaid Services (CMS) criteria for coverage be utilized in determining appropriate practitioners to render hyperbaric oxygen therapy.7 psi. Patients with stage III disease can receive up to 30 treatments followed by mandibular segmental resection and then an additional 10 treatments.0-2. 07/21/05. Refractory 2. and in on-campus provider-based departments for which provider-response time to the chamber can be expected to exceed five minutes. D. HBO therapy rendered within a hospital outpatient department is considered “incident to” a physician’s or qualified NPP’s services and requires physician supervision. process is refractory to up to 40-80 treatments. if such service is included within their State scope of practice.g. 09/17/09.01. Soft-tissue 2. it is recommended that the physician be present during the ascent and descent portions of each treatment. 02/17/11. certified as part of the hospital and part of the hospital campus). Qualified non-physician practitioners (NPPs) may supervise hyperbaric oxygen therapy services. and if the NPP meets the educational requirements identified within the coverage article. Non-responders are considered stage II and receive more extensive surgical debridement followed by 10 additional treatments. C. Advanced Cardiac Life Support (ACLS) training and certification of supervising physicians (and NPPs) is required in physician offices and off-campus hospital sites. 07/19/07. ATA treatment when the disease minutes. however. is 30 treatments. if their required supervision or collaborative agreement is with a physician qualified to provide HBOT services. or must have completed a minimum 40-hour training experience in a program such as one approved by the American College of Hyperbaric Medicine or the Undersea and Hyperbaric Medical Society. 09/21/06. 04/19/12. or 33 ft of seawater.

which in turn promotes wound healing. receptive language and eye contact. 03/19/15. 09/17/09. the physician (or qualified NPP) must be present in the office suite or at a location with a maximum of a five (5) minute response time to the chamber. or large chamber hyperbaric oxygen. or endotracheal tube. (Rossignol. 05/19/04. gangrenous lesion. It is hypothesized that the high concentrations of oxygen diffuses directly into the wound to increase the local cellular oxygen tension. 30% of the children in the treatment group had a score of 1 (very much improved) or 2 (much improved) compared to 8% in the control group. 02/17/11. 09/21/06. therefore it is not subject to U.SUBJECT: HYPERBARIC OXYGEN THERAPY EFFECTIVE DATE: 11/19/99 (HBOT) REVISED DATE: 04/17/02. conventional O2 tanks may be used. multi-place (multi-person) chamber pressurized with compressed air. Inc. There was no significant differences between-group improvement on the ABC total score. decubitus ulcers.07 03/20/14. Whether there are any long-term effects is not known. randomized controlled study on the use of HBOT to treat children with autism was published and included 62 children. but when results are compared to a control group. carbon monoxide poisoning. Treatment may be carried out either in a monoplace (single person) chamber pressurized with pure O2 or in a larger. The control group received a sham treatment consisting of 1. 30% of the children in the treatment group had a score of 1 or 2 compared to 15% in the control group. The active group received hyperbaric treatment at 1. 03/17/16 CATEGORY: Technology Assessment PAGE: 6 OF: 14 E. amputations. The hyperbaric chambers used to administer the therapy do require and have received FDA approval.03 atm and ambient air (21% oxygen). 04/19/12. families with children in the control group were offered the active intervention. Topical hyperbaric oxygen therapy describes a technique of delivering 100% O2 directly to a wound site at a pressure slightly higher than atmospheric pressure. any of the ABC subscales or on the ATEC total score. no difference was found as measured by the three clinical instruments. In order to satisfy the immediately available criteria. Further research is needed to determine if HBOT is an effective treatment for autism. In 2009. 03/21/13. POLICY NUMBER: 2. DESCRIPTION: Hyperbaric oxygen therapy (HBOT) is a technique of delivering highly pressurized oxygen to the tissues. ages 2-7.. typically a wound. for HBO therapy performed in an outpatient hospital on- campus or off-campus provider based department. significantly more children were rated as improved in the treatment group compared to control on 2 out of 18 subscales. The outcomes were change compared to baseline after 4 weeks several scales: Aberrant Behavior Checklist (ABC): Autism Treatment Evaluation Checklist (ATEC). This technique relies on the systemic circulation to deliver highly oxygenated blood to the target site. venous stasis. On the parental-rated CGI total score. in which case the patient receives pure oxygen by mask. head tent. Additional follow-up data cannot be obtained because members of the control group crossed over to the intervention after 4 weeks. . For HBO performed in a physician office. In addition. Other limitations include lack of adjustment for multiple comparisons and unclear clinical significance of the statistically significant outcomes.3 atmospheres (atm) and 24% oxygen in a hyperbaric chamber. Compared to the control group. The appliances may be disposable and may be used without supervision in the home by well-trained patients. Both groups received 40 sessions of active or sham treatment lasting 60 minutes each over a period of 4 weeks. On the physician-rated CGI total score. Topical HBOT devices consist of an appliance to enclose the wound area and a source of O2. 06/19/08. 07/19/07. skin graft or frostbite. a double-blind. A key limitation of the study was that the authors reported outcomes only directly after completion of the intervention.S. Topical HBO2 has been investigated as a treatment for skin ulcerations due to diabetes. 09/18/08. Food and Drug Administration (FDA) regulation. etc. Findings suggest improvements may be seen in some children with autism treated with HBOT. HBOT for autism spectrum disorders.01. the treatment group had a significant improvement in the ATEC sensory/cognitive awareness subscale. 07/21/05. post-surgical infection. Among the parental-rated CGI subscales. 2009) Proprietary Information of Excellus Health Plan. In systemic. the physician (or qualified NPP) must be present in the office suite. Two methods of administration are available. RATIONALE: Hyperbaric oxygen therapy is a procedure. clostridial gas gangrene. and Clinical Global Impression-Improvement (CGI). systemic hyperbaric oxygen therapy can be used to treat systemic illness such as air or gas embolism. diagnosed with an autistic disorder. 04/24/03. et al. After completion of the 4-week study. 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).

4 Actinomycotic infections (code range) 039. 03/17/16 CATEGORY: Technology Assessment PAGE: 7 OF: 14 In December 2009.8-039. (Lawrence.0 Gas gangrene 090. intratympanic steroids as either primary or salvage therapy may be considered. per 30 minute interval ICD9: 039. Code Key: Experimental/Investigational = (E/I). The use of HBOT for patients with chronic refractory osteomyelitis is supported by the Undersea and Hyperbaric Medical Society and the American College of Hyperbaric Medicine.0-039. the Undersea and Hyperbaric Medical Society issued a position paper stating they do not recommend routine treatment of autism with HBOT as there is very little evidence to support an effect of pressure alone or that oxygen has differing effects whether given by increasing ambient pressure or increasing the inspired fraction. CODES MAY NOT BE COVERED UNDER ALL CIRCUMSTANCES. HBOT for Idiopathic Sudden Sensorineural Hearing Loss: In 2015. full body chamber. symptomatic 095. 03/21/13. CODES: Number Description Eligibility for reimbursement is based upon the benefits set forth in the member’s subscriber contract. 09/18/08. 07/21/05. Published clinical trials have not provided evidence to support the efficacy and safety of hyperbaric oxygen therapy over current treatment options for the indications listed as investigational in this policy. POLICY NUMBER: 2. They stated the cost. Given the limited number of options available to patients with these late effects of radiation therapy. Inc. Not medically necessary/ appropriate = (NMN). et al. A retrospective case series of 65 patients with radiation enteritis/proctitis and 94 patients with cystitis were reported from one institution. 06/19/08. Response was better in patients receiving 30 or more total treatments compared with fewer treatments. CPT: 99183 Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy. per session Copyright © 2016 American Medical Association. limited availability and lack of strong evidence for HBOT makes it impractical at present. A Cochrane Review of randomized trials concluded that available small trials suggest that for people with late radiation tissue injury affecting the head. Chicago. The authors concluded if the hearing loss is idiopathic in nature patients may be offered a course of oral steroid. 04/24/03. . 09/21/06. PLEASE READ THE POLICY AND GUIDELINES STATEMENTS CAREFULLY. 07/19/07. anus and rectum. IL HCPCS: A4575 (E/I) Topical hyperbaric oxygen chamber. If systemic steroids are contraindicated and/or there is no improvement with initial oral therapy. HBOT is associated with improved outcomes. an evidence-based literature review was reported that addresses the controversies in the management of sudden sensorineural hearing loss and proposes a treatment algorithm based on the highest quality evidence. disposable G0277 Hyperbaric oxygen under pressure. 02/17/11. 05/19/04.SUBJECT: HYPERBARIC OXYGEN THERAPY EFFECTIVE DATE: 11/19/99 (HBOT) REVISED DATE: 04/17/02.9 040. 03/19/15. neck. Codes may not be all inclusive as the AMA and CMS code updates may occur more frequently than policy updates.07 03/20/14. 09/17/09. Although no randomized clinical trials examining the effects of HBOT on chronic refractory osteomyelitis have been identified the substantial majority of available human case series and non-randomized prospective trials suggest that the addition of HBOT to routine surgical and antibiotic management in previously refractory osteomyelitis is safe and improves the ultimate rate of infection resolution. HBOT also appears to reduce the change of osteoradionecrosis following tooth extraction in an irradiated field. 04/19/12.0 Early congenital syphilis. results of cohort studies as well as randomized trials were used in evaluating clinical evidence.01.5 Syphilis of bone Proprietary Information of Excellus Health Plan. 2015) HBOT for radiation necrosis and osteoradionecrosis.

fumes or vapors.9 Other cellulitis and abscess (code range) 686.9 117.4 Osteomyelitis of jaw 526.0-112. 09/21/06. hydrocyanic acid gas 989.8-111.89 Osteoradionecrosis of jaw 682.81-112.9 Other local infections of skin and subcutaneous tissue (code range) 730. implant.00-686.9 Other and unspecified mycoses 250.8 Cerebral edema.01 Tuberculosis of spine A18.69 Infection and inflammatory reaction due to internal prosthetic device. Inc.3 Decompression sickness (Caisson Disease) 996.90-730. unspecified 993. implant.3 Dermatomycosis. 04/19/12.8 767. acute 986.0 Toxic effect of carbon monoxide poisoning 987. fetus or newborn (due to birth injury) 785.99 Unspecified infection of bone (code range) 767.80-250.07 03/20/14. chiefly nonmedical as to source.9 112. POLICY NUMBER: 2. 03/19/15. 07/19/07.0-111.2 Crush injury (code range) 958.83 Diabetic osteomyelitis 285. 07/21/05. 09/17/09.29 Osteomyelitis (code range) 730.79 Other complications of internal (biological ) (synthetic) prosthetic device.0-682.80-730. and graft ICD10: A18.03 Tuberculosis of other bones Proprietary Information of Excellus Health Plan. 06/19/08. 04/24/03. graft due to graft of other tissue 996. 03/21/13.4 Gangrene 909.00-730.2 Late effect of radiation 925.1-925. 03/17/16 CATEGORY: Technology Assessment PAGE: 8 OF: 14 111. 05/19/04.03 Orbital osteomyelitis 526. implant and graft 996. other and unspecified (code range) 111.89 Other infections involving bone (osteomyelitis) in disease classified elsewhere (code range) 730.01.7 Toxic effect of other gases. acute 990 Effects of radiation. 02/17/11.5 Candidiasis (mucomycosis) (code range) 112. cyanide poisoning.SUBJECT: HYPERBARIC OXYGEN THERAPY EFFECTIVE DATE: 11/19/99 (HBOT) REVISED DATE: 04/17/02.0 Toxic effect of other substances.1 Acute posthemorrhagic anemia 348. and graft due to other internal prosthetic device.5 Cerebral edema 376.52 Mechanical complication of other specified prosthetic device. . implant.0 Gas (air) embolism. 09/18/08.

unspecified A43. 09/17/09.81-A42.09 Early congenital syphilis.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11-618-E11.769 Atherosclerosis of bypass graft(s) of the extremities with gangrene (code range) I70.01 Raynaud's syndrome with gangrene I96 Gangrene. not elsewhere classified K12. symptomatic (code range) A52.0-B36. POLICY NUMBER: 2. 04/19/12.6 Cerebral edema H05.91 Cutaneous abscess (code range) L03.129 Acute lymphangitis (code range) L03.01.1-B47.0-A43. 04/24/03. 06/19/08.07 03/20/14.2 Cellulitis and abscess of mouth L02.021-H05.9 Nocardiosis (code range) A48.52-E13.469 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene (code range) I73.3 Geotrichosis B48.69 Other specified diabetes mellitus (code range) G93.618-E10. 02/17/11.029 Osteomyelitis of orbit (code range) I70.77 Syphilis of bone and joint B36.361-I70.89 Other forms of actinomycosis (code range) A42. 07/19/07.2 Actinomycosis (code range) A42. .52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E09.9 Other superficial mycoses (code range) B47.SUBJECT: HYPERBARIC OXYGEN THERAPY EFFECTIVE DATE: 11/19/99 (HBOT) REVISED DATE: 04/17/02. Inc. 09/21/06.119 Cellulitis (code range) L03. 09/18/08.69 Type 1 diabetes mellitus with other specified complications (code range) E11.01-A50.211-L03. 05/19/04. 03/19/15.69 Type 2 diabetes mellitus with other specified complication E13. 03/21/13. 03/17/16 CATEGORY: Technology Assessment PAGE: 9 OF: 14 A42. 07/21/05.111-L03.0-A42.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.121-L03.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.0 Gas gangrene A50.461-I70.9 Mycetoma (code range) B48.8 Other specified mycoses B49 Unspecified mycosis D62 Acute posthemorrhagic anemia E08.01-L02.91 Cellulitis and acute lymphangitis (code range) Proprietary Information of Excellus Health Plan.9 Actinomycosis.

Pressure ulcer treatment strategies: comparative effectiveness. 04/19/12.2 Inflammatory conditions of jaws M27. 06/19/08.0 Cerebral edema due to birth injury S06.S06.gov/search-for-guides-reviews-and- reports/?pageaction=displayproduct&productid=1492] accessed 2/9/16.SUBJECT: HYPERBARIC OXYGEN THERAPY EFFECTIVE DATE: 11/19/99 (HBOT) REVISED DATE: 04/17/02.T58. . 09/21/06.01.org/faq/] accessed 2/9/16. 90.820-T86. initial encounter T70.3xxA Caisson disease (decompression sickness). MD.effectivehealthcare.89 Osteopathy in diseases classified elsewhere (code range) P11. 2013 May [http://www. 03/17/16 CATEGORY: Technology Assessment PAGE: 10 OF: 14 L08.T65.19 Other acute osteomyelitis (code range) M86.8x0-M86.51(2):138-52.20-M86. 13-EHC003-EF.822 Complications of skin graft (allograft) (autograft) (code range) T86.30-M46. initial encounter T86.00-M86.T57.829 Other and unspecified complications of skin graft (allograft) (autograft) (code range) REFERENCES: Agency for Healthcare Research and Quality.01xA.9 Disorder of the skin and subcutaneous tissue related to radiation. What are the approved indications for hyperbaric oxygen therapy? [http://www.0xxA Air embolism (traumatic).S17. 05/19/04. initial encounter T79.9xxA Crushing injury (code range) T57.1x0A.94xA Toxic effect of carbon monoxide (code range) T65. Saha S. 09/17/09. 09/18/08. American College of Hyperbaric Medicine. Frequently asked questions. Proprietary Information of Excellus Health Plan. AHRQ Publication No.1x9A Traumatic cerebral edema without loss of consciousness (code range) S07.ahrq. 03/19/15. et al.29 Subacute osteomyelitis (code range) M86.28 Osteomyelitis of vertebra (code range) M46. Inc.0xxA.80-M90. 04/24/03.10-M86. 07/19/07. POLICY NUMBER: 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. 02/17/11. 03/21/13.3x1A.09 Acute hematogenous osteomyelitis (code range) M86. unspecified. Ann Emerg Med 2008 Feb.0x4A Toxic effect of cyanides (code range) T66. 07/21/05.20-M46.07 03/20/14.3 Eosinophilic cellulitis (Wells) M27.1 Erythrasma L59. Rockville.828-T86.xxxA Radiation sickness.3x4A Toxic effect of hydrogen cyanide (code range) T58.9 Other and unspecified osteomyelitis (code range) M90.39 Infection of intervertebral disc (pyogenic) (code range) M86. unspecified L98.0x1A.achm.30-M86. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with acute carbon monoxide poisoning. Comparative Effectiveness Review No.69 Chronic osteomyelitis (code range) M86.8 Other specified diseases of jaws M46.

Ottawa: Canadian Agency for Drugs and Technologies in Health. Bennett MH. Cochrane Database Syst Rev 2014 Nov 12. Issue 4. *Bennett M. No CD004818. Cochrane Database of Systematic Reviews 2015. 05/19/04. Churchill S. 04/24/03. Bennett MH. Cochrane Database Syst Rev.cadth. Hyperbaric oxygen for tumour sensitisation to radiotherapy. A prospective trial of hyperbaric oxygen for chronic sequelae after brain injury (HYBOBI). Hyperbaric oxygen therapy. 04/19/12. Inc. Baynosa RC and Zamboni WA.11:CD004712.(12):CD004609. Hyperbaric oxygen for carbon monoxide poisoning.40(2):165-93. Hyperbaric oxygen therapy for multiple sclerosis. 2012 Nov 14. 02/17/11. 03/21/13. Cochrane Database of Systematic Reviews 2011.pdf] accessed 2/9/16. et al.40(5):419-38.cadth. et al. Cochrane Database Syst Rev. Issue 1. The effect of hyperbaric oxygen on compromised grafts and flaps. et al.: CD002041. 03/19/15. *Canadian Agency for Drugs and Technologies in Health. Hyperbaric oxygen therapy for acute domestic carbon monoxide poisoning: two randomized controlled trials. 2009 Dec 5 [https://www. et al. Hyperbaric oxygen therapy for late radiation tissue injury. No.ca/media/pdf/M0016_HBOT_L3_e. *Bennett MH. *Bennett MH. Cochrane Database Syst Rev 2005 Oct 19.uhms. et al. 2012 May 16. Hyperbaric oxygen therapy for autism: a review of the clinical and cost-effectiveness. Undersea Hyperb Med 2013 Sep- Oct. *Bennett M. Bennett MH. *Bennett M. et al. Cochrane Database Syst Rev 2015.: CD003057. Art. *Bennett M. Hyperbaric oxygen for acute coronary syndrome. 2015 Aug 13.01. 07/21/05. 2012 Oct 17. Cochrane Database Syst Rev 2012 Apr 18. Hyperbaric oxygen therapy for delayed onset muscle soreness and closed soft tissue injury. .pdf] accessed 2/9/16.04.: CD005219. et al. Undersea Hyperb Med 2013 Mar-Apr.pdf] accessed 2/9/16. 09/18/08.39(4):857-65. Cochrane Database Syst Rev. Bennett M.07 03/20/14. Issue 12. Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non-union. Art.01. *Boudreau R. The treatment of autism spectrum disorder with hyperbaric oxygen therapy. 09/17/09.10:CD004739. Art. et al. et al. et al.ca/media/pdf/L0141_Hyperbaric_Oxygen_final. No. Intensive Care Med 2011 Mar.5:CD005005. Randomized controlled trials in diving and hyperbaric medicine. et al. Normobaric and hyperbaric oxygen therapy for migraine and cluster headache. 09/21/06.org/images/Position-Statements/autism_position_paper. POLICY NUMBER: 2. et al. et al. Hyperbaric oxygen therapy for acute ischaemic stroke. Undersea Hyperb Med 2012 Jul-Aug. Hyperbaric oxygen therapy for the adjunctive treatment of traumatic brain injury. et al. 2010 Jun [http://www. Cochrane Database Syst Rev 2004. Bennett MH. Issue 7. 07/19/07.SUBJECT: HYPERBARIC OXYGEN THERAPY EFFECTIVE DATE: 11/19/99 (HBOT) REVISED DATE: 04/17/02.11:CD004954. 06/19/08. Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus.37(3):486-92. Art. Bennett MH. UHMS position paper. 03/17/16 CATEGORY: Technology Assessment PAGE: 11 OF: 14 Annane D. 2009 Nov 19 [http://www.(4):CD004713. Hyperbaric oxygen therapy for difficult wound healing: systematic review of clinical effectiveness and cost-effectiveness. et al. Medical Policy Reference Manual Policy #2. Cochrane Database Syst Rev 2012 Dec 12. BlueCross BlueShield Association. Proprietary Information of Excellus Health Plan.4:CD005007. No. Buckley NA.

2012 Feb 15. Huang ET.(12): CD008059. Hyperbaric oxygen therapy and delayed radiation injuries (soft tissue and bony necrosis): 2012 update. et al. Aliment Pharmacol Ther 2014 Jun. 04/19/12. 06/19/08. double-blind. 04/24/03. Löndahl M. Inc. Clin Otolaryngol 2015 Jun. POLICY NUMBER: 2. Cochrane Database Syst Rev 2005 Jan 25. et al.35(3):535-42. Fedorko L. et al. Art.(1):CD002041.30(1):3-23. Proprietary Information of Excellus Health Plan. Feldmeier JJ. Löndahl M.(9):CD003603. Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. et al. et al. Kot J and Mathieu D.: CD007937. Eskes AM. Diabetes Care 2016 Jan 6. et al. International Task Force on Osteonecrosis of the Jaw. Hyperbaric oxygen therapy: solution for difficult to heal acute wounds? Systematic review. Systematic review: The safety and efficacy of hyperbaric oxygen therapy for inflammatory bowel disease. Diving Hyperb Med 2011 Jun. randomized controlled clinical trial. Systematic review of the effectiveness of hyperbaric oxygenation therapy in the management of chronic diabetic foot ulcers. A systematic review of the literature reporting the application of hyperbaric oxygen prevention and treatment of delayed injuries: an evidence-based approach. Khan AA. Hyperbaric oxygen therapy for chronic wounds. pii: dc152001 [Epub ahead of print].28(2):186-90.42(3):205-47. Controversies in the management of sudden sensorineural hearing loss: an evidence- based review. Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus. 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. et al. 05/19/04. World J Surg 2011 Mar.29(1):4-29. Cochrane Database Syst Rev 2013 Dec 16.01. Hyperbaric oxygen therapy for Bell's palsy. 03/17/16 CATEGORY: Technology Assessment PAGE: 12 OF: 14 Dauwe PB. Undersea Hyperbaric Med 2002. *Juurlink DN. Diabet Med 2011 Feb. J Bone Miner Res 2015 Jan.88(2):166-75.133(2):208e-15e. Hyperbaric oxygen therapy for treating acute surgical and traumatic wounds. et al. Levett D. *Esposito M. No. 03/19/15. Holland S. Controversial issues in hyperbaric oxygen therapy: a European Committee for Hyperbaric Medicine Workshop. UHMS CPG Oversight Committee. *Feldmeier JJ and Hampson NB. Hyperbaric oxygen therapy does not reduce indications for amputation in patients with diabetes with nonhealing ulcers of the lower limb: a prospective. et al. et al. Mayo Clin Proc 2013 Feb. Undersea Hyperb Med 2015 May-Jun.39(6):1121-39. Cochrane Database of Systematic Reviews 2015.41(2):101-4. What is the role of hyperbaric oxygen in the management of diabetic foot disease? Curr Diab Rep 2011 Aug. Eskes A. Cochrane Database Syst Rev.11(4):285-93. A clinical practice guideline for the use of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers. 09/17/09. 02/17/11. 09/21/06. Neurology 2012 Apr 24. Liu R. Undersea Hyperb Med 2012 Nov-Dec.6:CD004123. et al. Holland NJ. et al. et al. Interventions for replacing missing teeth: hyperbaric oxygen therapy for irradiated patients who require dental implants.07 03/20/14.SUBJECT: HYPERBARIC OXYGEN THERAPY EFFECTIVE DATE: 11/19/99 (HBOT) REVISED DATE: 04/17/02. Hyperbaric oxygen therapy improves health-related quality of life in patients with diabetes and chronic foot ulcer. Issue 1. 07/21/05. Adjunctive hyperbaric oxygen for necrotizing fasciitis.2:CD007288. Hyperbaric oxygen for carbon monoxide poisoning. Cochrane Database Syst Rev 2015. Does hyperbaric oxygen therapy work in facilitating acute wound healing: a systematic review.39(11):1266-75. Lawrence R and Thevasagayam R.78(17):1346-53. Cochrane Database Syst Rev 2013 Sep 30. et al. . Plast Reconstr Surg 2014 Feb. 09/18/08. 03/21/13.40(3):176-82. 07/19/07. Dulai PS. Kranke P et al. et al.

*Piantadosi CA. Undersea Hyperb Med 2011 Mar-Apr. Cochrane Database Syst Rev 2013 May 31. 09/21/06. 03/17/16 CATEGORY: Technology Assessment PAGE: 13 OF: 14 Michalski D. Eur J Vasc Endovasc Surg 2014 Jun.uhms. 03/19/15. Hyperbaric oxygen therapy for vascular dementia. Inc. *Weaver LK. randomized.uhms. 2011 Oct 8 [https://www. 02/17/11. NEJM 2002 Oct 3. Acta Neurol Scand 2011 Feb. Xiao Y. Stachler RJ. Undated. Chemical. et al. Cochrane Database of Systematic Reviews 2004. Position Statement. Hyperbaric oxygen therapy for thermal burns.42(3):128-33.5:CD004617.112(7):885-97. Undersea and Hyperbaric Medical Society. Phillips JS and Jones SE. 347(14):1054–5. NEJM 2002 Oct 3. et al. Moon RE.org/images/Position-Statements/2003_brain_injury. 05/19/04. BJU Int 2013 Nov. Position statement. 2014. [https://www.01. Hyperbaric oxygen for the treatment of diabetic foot ulcers: a systematic review. No.7:CD009425.123(2):85-97. Hyperbaric oxygen treatment for decompression sickness. Position Statement.41(2):151-7.org/14-idiopathic-sudden-sensorineural-hearing-loss-new-approved-on-october-8-2011-by-the-uhms- board-of-directors.347(14):1057–67. Idiopathic sudden sensorineural hearing loss. Durham. Issue 2. Topical hyperbaric oxygen therapy.146(3 Suppl):S1-35. Clinical practice guideline: sudden hearing loss. Art.: CD004727. et al.pdf] accessed 2/9/16. 07/19/07. O'Reilly D. 2012 Jul 11.47(6):647-55. *Villanueva E. Topical hyperbaric oxygen pressurization. 13th Edition. TOWT.38(2):109-15. Undersea and Hyperbaric Medical Society. Topical oxygen wound therapy. *Undersea and Hyperbaric Medical Society. 03/21/13. *Undersea and Hyperbaric Medical Society. Hyperbaric oxygen therapy indications. Diving Hyperb Med 2012 Sep. et al.07 03/20/14. . Hyperbaric oxygen for chronic brain injury. 07/21/05. et al. Proprietary Information of Excellus Health Plan. Hyperbaric oxygen as an adjuvant treatment for malignant otitis externa. 04/19/12.a preclinical and clinical review. 2003 Nov [https://www.39(3):777-92. Perspective: carbon monoxide poisoning. et al.uhms. Payne H. The effect of hyperbaric oxygen on clinical outcome of patients after resection of meningiomas with conspicuous peritumoral brain edema. 04/24/03. Otolaryngol Head Neck Surg 2012 Mar. Murphy-Lavoie H. Trials 2011 Mar 7.SUBJECT: HYPERBARIC OXYGEN THERAPY EFFECTIVE DATE: 11/19/99 (HBOT) REVISED DATE: 04/17/02. et al. Use of normobaric and hyperbaric oxygen in acute focal cerebral ischemia . 09/17/09.and radiation-induced haemorrhagic cystitis: current treatments and challenges. et al. Undersea Hyperb Med 2012 May-Jun. controlled clinical trial comparing standard wound care with adjunctive hyperbaric oxygen therapy (HBOT) to standard wound care only for the treatment of chronic. NC.pdf] accessed 2/9/16. Cochrane Database Syst Rev. The Hyperbaric Oxygen Therapy Committee Report. Systemic hyperbaric oxygen therapy. Sampanthavivat M. POLICY NUMBER: 2. non-healing ulcers of the lower limb in patients with diabetes mellitus: a study protocol. double-blind. 06/19/08. et al.html] accessed 2/9/16. Hyperbaric oxygen in the treatment of childhood autism: a randomised controlled trial. KEY WORDS: HBOT. The treatment of multiple sclerosis with hyperbaric oxygen therapy. Hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss. A prospective. et al. Tang X. Undersea Hyperb Med 2014 Mar-Apr. 09/18/08. Hyperbaric oxygen for acute carbon monoxide poisoning. Stoekenbroek RM.org/images/Position-Statements/treatment_of_multiple_sclero. et al. American Academy of Otolaryngology-Head and Neck Surgery.12:69.

09/21/06.aspx?NCDId=12&ncdver=3&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=New+York+- +Entire+State&KeyWord=hyperbaric&KeyWordLookUp=Title&KeyWordSearchType=And&articleId=52174&ver=24 &ContrId=298&ContrVer=1&bc=gAAAABAAAAAAAA%3d%3d& LCA: https://www.07 03/20/14.SUBJECT: HYPERBARIC OXYGEN THERAPY EFFECTIVE DATE: 11/19/99 (HBOT) REVISED DATE: 04/17/02. 04/24/03. 07/19/07.aspx?articleId=52380&ver=11&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=New+York+- +Entire+State&KeyWord=hyperbaric&KeyWordLookUp=Title&KeyWordSearchType=And&ContrId=298&ContrVer= 1&bc=gAAAABAAAAAAAA%3d%3d& Proprietary Information of Excellus Health Plan. 09/17/09.gov/medicare-coverage-database/details/ncd- details. 02/17/11. 07/21/05. 06/19/08. 05/19/04. 03/19/15. 03/21/13. . Inc. 09/18/08. 03/17/16 CATEGORY: Technology Assessment PAGE: 14 OF: 14 CMS COVERAGE FOR MEDICARE PRODUCT MEMBERS There is currently a National Coverage Determination (NCD) and a Local Coverage Article for Hyperbaric Oxygen Therapy.cms.cms. POLICY NUMBER: 2.01.gov/medicare-coverage-database/details/article- details. Please refer to the following websites for Medicare Members: NCD: https://www. 04/19/12.