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CurrentAlliance HealthPolicy 1A-8

Hyperbaric Oxygenation Therapy (HBO) — NC Medicaid Clinical Coverage Policy

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This policy governs coverage and utilization of hyperbaric oxygen (HBO) therapy for NC Medicaid beneficiaries, specifying covered indications, exclusions, prior approval and EPSDT considerations. It affects providers delivering HBO services to Medicaid enrollees in North Carolina.

Policy Summary

PayerAlliance Health

PolicyHyperbaric Oxygenation Therapy (HBO) — NC Medicaid Clinical Coverage Policy

Policy CodePolicy 1A-8

Change TypeNo material change

Effective Date

Last ReviewAug 15, 2023

Next Review Date

Key ActionObtain prior approval before initiating HBO therapy; initial approvals are for 30 days and extensions require subsequent prior authorization with supporting documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysinitial prior approval period

30 daysstandard wound therapy trial

Wagner III+diabetic wound severity threshold

24non-covered specific conditions

1 sessionbilling unit

Coverage Criteria for Hyperbaric Oxygen Therapy

Covered Indications and General Medical Necessity

Covered when ALL of the following general Medicaid medical necessity requirements are met and one of the specific covered indications applies:

General Medicaid medical necessity: Procedure is individualized, specific, and consistent with symptoms or confirmed diagnosis; is safely furnished and no equally effective and more conservative or less costly treatment is available statewide; and is not furnished primarily for the convenience of the beneficiary, caretaker, or provider.

Based on Section 3.1

Specific covered indications (select one)

Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment.
Section 3.2.1(a)
Acute carbon monoxide intoxication.
Section 3.2.1(b)

Policy Summary

PayerAlliance Health

PolicyHyperbaric Oxygenation Therapy (HBO) — NC Medicaid Clinical Coverage Policy

Policy CodePolicy 1A-8

Change TypeNo material change

Effective Date

Last ReviewAug 15, 2023

Next Review Date

Key ActionObtain prior approval before initiating HBO therapy; initial approvals are for 30 days and extensions require subsequent prior authorization with supporting documentation.

SourceLink

On This Page

A fuller list of conditions Medicaid shall not cover for HBO therapy includes: acute cerebral edema; acute or chronic cerebral vascular insufficiency; acute thermal/chemical pulmonary damage with pulmonary insufficiency; aerobic septicemia; anaerobic septicemia and infection other than clostridial; arthritic diseases; cardiogenic shock; chronic peripheral vascular insufficiency (except as noted elsewhere in the policy); congenital conditions (e.g., cerebral palsy, autism, intellectual disability); cutaneous, decubitus, and stasis ulcers; exceptional blood loss anemia; hepatic necrosis; multiple sclerosis; myocardial infarction; nonvascular chronic brain syndromes (Pick’s, Alzheimer’s, Korsakoff’s); organ storage and organ transplantation; pulmonary emphysema; senility; sickle cell crisis; thermal skin burns; systemic aerobic infection; tetanus; and traumatic brain injury.

Coding, Billing Units and Code Mappings

Coding sections referenced (ICD-10-CM, PCS, CPT, Modifiers, Billing Units, Place of Service)mixed

No codes listed

Claim Typesmixed

No codes listed

Coding guidancemixed

No codes listed

ICD-10-CM/PCS mappings (sample entries — full list in document)ICD-10

M87.343	ICD-10-CM code listed in attachment
S55.902A	ICD-10-CM code listed in attachment
S78.022S	ICD-10-CM code listed in attachment
5A05121	ICD-10-PCS code referenced as added in revision note (08/15/2019)

ICD-10-CM and PCS codes (partial list shown)ICD-10

M86.441
S88.121A
M89.661
S65.912A
S88.121D
M86.442
M89.662
S65.919A
M86.449
M89.669

1–10 of 275

1/28

ProfessionalCPTCovered

99183

Professional

FacilitymixedCovered

RC413	Facility
5A05121	ICD-10-PCS: Extracorporeal Hyperbaric Oxygenation, Intermittent

Unlisted Procedure or Servicemixed

Unlisted CPT/HCPCS

See CPT/HCPCS instructions and Special Report for unlisted procedure or service

inv-17: Standard wound therapy trial duration — 30 consecutive days

Standard wound therapy trial durationFailure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days; HBO allowed only after this trial

Wound evaluation frequency during HBOWounds must be evaluated at least every 30 days during administration of HBO therapy

Wagner grade threshold for diabetic lower extremity woundsWagner Grade III or higher is required for coverage

Adjunctive use requirementHBO is covered as adjunctive therapy and must be used in addition to standard wound care

Discontinuation ruleContinued HBO is not covered if measurable signs of healing are not demonstrated within any 30-day period of treatment

inv-18: Transcutaneous PO2 threshold (for chronic peripheral vascular insufficiency) — < 40 mmHg breathing air

Transcutaneous PO2 thresholdFor chronic peripheral vascular insufficiency coverage, transcutaneous PO2 breathing air must be less than 40 mmHg

Arterial inflow evaluation requirementArterial inflow investigation must show no lesions amenable to bypass or stenting before coverage consideration

Context of useThreshold applied when assessing chronic peripheral vascular insufficiency as a covered indication

inv-19: Radiation dose threshold for irradiated jaw dental surgery — > 5000 cGy

Radiation dose thresholdPre- and post-dental surgery of an irradiated jaw is covered only when the jaw received total radiation dose greater than 5000 cGy

Procedure limitationCoverage applies to non-implant related dental surgery on irradiated jaw exceeding the dose threshold

Role of HBOHBO considered adjunctive in management of irradiated-tissue complications surrounding dental surgery

inv-20: Billing unit — One unit = one session

Billing unit definitionOne unit = one session

Coding dependencyProvider(s) shall report the appropriate code(s) which determine the billing unit(s)

Session reporting implicationEach HBO treatment session is billed as a single unit according to the reported code

Prior Authorization, Documentation and Billing Requirements

Prior Authorization

Prior approval required; EPSDT note

Medicaid requires prior approval before rendering hyperbaric oxygenation therapy; EPSDT does not eliminate prior approval requirements for beneficiaries under 21 — providers must document EPSDT medical necessity when applicable.

Obtain PA before providing HBO therapy.
For beneficiaries under 21, include documentation showing how the service meets EPSDT criteria.

Prior Authorization

Initial 30-day approval and extension/urgent submission

Initial prior approval is granted for 30 calendar days; treatment beyond 30 days requires a second prior approval request. In urgent situations, submit the PA within five calendar days to allow authorization back to the first date of treatment when criteria are met.

Initial PA period = 30 days; subsequent PA required for continued treatment.
For urgent cases, submit PA within 5 calendar days of treatment start; first day of treatment is day one.

Prior Authorization

Follow NCTracks / DHHS UR contractor guidance for PA

Providers must follow NCTracks and Medicaid program guidance for prior authorization submission and processing and submit PA requests and supporting records to the DHHS Utilization Review Contractor as directed.

Submit PA request and all supporting health records to the DHHS Utilization Review Contractor.
Follow NCTracks and other Medicaid program guidance for PA processes.

Note

Policy and amendment reference (1A-8, amended 08/15/2023)

This policy is NC Medicaid Clinical Coverage Policy No. 1A-8 (Amended August 15, 2023); prior authorization requirements are specified in Sections 5.1–5.3 of this policy and related attachments.

Policy identifier: Clinical Coverage Policy No. 1A-8; Amended Date: August 15, 2023.
Refer to Sections 5.1–5.3 for PA details.

Prior Authorization

Prior authorization coding guidance — use current, most-specific codes

Report the most specific, current codes in effect at the time of service; use current CPT/HCPCS/ICD editions and refer to the applicable codebook descriptions. If no specific CPT/HCPCS code exists, use the appropriate unlisted code following codebook instructions.

Use the current CPT, HCPCS, ICD-10-CM/PCS and UB-04 data manuals in effect at time of service.
If using an unlisted CPT/HCPCS code, follow the codebook Instructions for Use and submit the required Special Report.

Step Therapy

Required trial: ≥30 days of standard wound therapy before HBO

For diabetic lower extremity wounds, HBO is covered only as adjunctive therapy after failure to show measurable healing for at least 30 consecutive days of standard wound therapy.

Standard wound therapy must have been provided for at least 30 consecutive days with no measurable signs of healing.
HBO must be used in addition to standard wound care (not as replacement).

Documentation Required

Document conventional treatment history (therapies, durations, outcomes)

Prior approval requests must document conventional treatment history including each therapy tried, duration, and outcomes to demonstrate failure of standard care.

Include conventional treatment history with duration and outcomes for each therapy.
Provide treatment plan and dates as part of the PA submission.

Note

Billing Rule

Required ICD-10-CM diagnosis pairing (Table A with Table B)

Billing: Table A ICD-10-CM diagnosis codes must be billed with the appropriate diabetic diagnosis codes from Table B for the specified diabetic lower-extremity wound pairings; failure to pair may trigger denials.

Ensure ICD-10-CM Table A codes are submitted with the corresponding Table B diabetic diagnosis codes as listed.
Noncompliant diagnosis pairing may result in claim denial.

Billing Rule

Claims must comply with NCTracks and Medicaid billing guidance

Claims must comply with NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, NC Medicaid clinical coverage policies, and all applicable national billing/coding guidelines.

Follow NCTracks Provider Claims and Billing Assistance Guide and Medicaid bulletins for claim submission.
Adhere to fee schedules and policy-specific billing instructions.

Documentation Required

Documentation expectations: EPSDT and diabetic wound follow-up

For beneficiaries under 21, include EPSDT-specific documentation showing how HBO meets EPSDT medical necessity; for diabetic wounds, documentation must show failure of at least 30 consecutive days of standard wound therapy and wounds are evaluated at least every 30 days during HBO.

EPSDT: document how the requested HBO corrects, ameliorates, or prevents worsening of the beneficiary's condition.
Document wound evaluations at least every 30 days during HBO and stop treatment if no measurable healing within any 30-day period.

Billing Rule

Institutional billing must follow UB-04/National Uniform Billing Guidelines

Institutional claims must be billed according to the National Uniform Billing Guidelines (UB-04/837I) and all claims must comply with National Coding Guidelines; failure to do so risks denial.

Institutional claims: bill per National Uniform Billing Guidelines.
All claims: comply with National Coding Guidelines.

Prior Authorization

Required documentation to accompany PA request

Submit the completed prior approval request along with all supporting health records demonstrating that the criteria in Subsection 3.2 are met, including diagnoses, onset date, conventional treatment history (with durations/outcomes), and the treatment plan with duration.

Attach all relevant health records that support each Subsection 3.2 criterion.
Include acceptance of the case by the HBO facility medical director (or designee) when requested.

Billing Rule

Report most-specific ICD-10-CM/PCS codes (current edition)

Report ICD-10-CM and ICD-10-PCS codes to the highest level of specificity that supports medical necessity and use the ICD edition in effect at the time of service.

Use the current ICD-10 edition in effect at time of service.
Report codes to the highest level of specificity that supports medical necessity.

Billing Rule

Unlisted CPT/HCPCS code reporting and Special Report required

When using unlisted CPT or HCPCS procedure codes, follow the CPT/HCPCS codebook Instructions for Use for unlisted procedures and submit the required Special Report as documented in the current codebooks.

Follow CPT/HCPCS Unlisted Procedure instructions.
Include the Special Report required by the current codebook edition.

Denial Risk

Denial triggers: eligibility, coverage criteria, duplication, experimental services

Services will be denied when the beneficiary does not meet Section 2.0 eligibility or Section 3.0 coverage criteria, when the service duplicates another provider's service, or when the service is experimental/investigational or part of a clinical trial.

Verify beneficiary eligibility per Section 2.0 and coverage criteria per Section 3.0 before providing HBO.
Do not submit claims for experimental/investigational or trial-related services.

Denial Risk

General denial triggers (Sections 2.0 and 3.0)

General denial reasons include failure to meet eligibility (Section 2.0) or coverage criteria (Section 3.0), duplicate services, or services that are experimental, investigational, or part of a clinical trial.

Confirm criteria in Sections 2.0 and 3.0 are met and document accordingly.
Avoid duplicate billing for the same service.

Note

Denial Risk

Denial risk: missing required diagnosis pairing (Table A/Table B)

Failure to bill Table A ICD-10-CM codes with the appropriate diabetic diagnosis codes from Table B when required may trigger claim denials; ensure diagnosis pairings match the policy's Table A/Table B specifications.

Verify each Table A diagnosis is billed with the corresponding Table B diabetic diagnosis as listed.
Claims lacking required diagnosis pairing are at risk for denial.

Denial Risk

Denial risk: insufficiently specific or outdated codes

Failure to report the most specific CPT/HCPCS/ICD-10-PCS code in effect at the time of service may lead to claim denial or incorrect processing; providers must use current code editions and the most specific code available.

Use the applicable code edition in effect at time of service.
Report the most specific code that accurately describes the service.

Definitions

Hyperbaric oxygen (HBO) therapy definition — entire body exposure to 100% oxygen at >1 ATA in a pressurized chamber

HBO therapy definitionExposure of the entire body to 100% oxygen at pressures greater than one atmosphere absolute (ATA) in a mono- or multi-place pressurized chamber

AdministrationDelivered according to accepted clinical protocols for duration and pressure

ScopeWhole-body exposure in a pressurized chamber (not topical oxygen application)

EPSDT definition — Early and Periodic Screening, Diagnostic, and Treatment federal Medicaid provision

EPSDT definitionEarly and Periodic Screening, Diagnostic, and Treatment (EPSDT): federal Medicaid requirement obligating coverage for medically necessary services for beneficiaries under 21 to correct or ameliorate a health problem

Scope for beneficiaries under 21EPSDT may require exceeding service limits if provider documentation shows the service is medically necessary to correct or ameliorate a condition

LimitationsEPSDT does not require coverage of services that are unsafe, ineffective, experimental, or not generally recognized as medical

Hyperbaric Oxygenation Therapy (HBO) — NC Medicaid Clinical Coverage Policy

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Coverage Criteria for Hyperbaric Oxygen Therapy

Coding, Billing Units and Code Mappings

Prior Authorization, Documentation and Billing Requirements

Background and Scope

Definitions