Hyperbaric Oxygen Therapy (HBOT)

Coverage Summary

This Part 1 of 3 defines the policy scope for hyperbaric oxygen therapy (HBOT) and summarizes coverage: systemic HBOT is MEDICALLY NECESSARY for specified systemic indications and topical HBOT is INVESTIGATIONAL / NOT COVERED. The policy lists explicit medically necessary systemic indications (e.g., non-healing diabetic lower-extremity wounds meeting Wagner criteria, decompression sickness, gas embolism, carbon monoxide and cyanide poisoning, soft-tissue and osseous radiation necrosis, gas gangrene, chronic refractory osteomyelitis, compromised skin grafts/flaps, progressive necrotizing soft-tissue infections, profound anemia when transfusion is impossible/delayed, pre/post treatment of irradiated jaw for dental surgery, SSNHL as salvage when combined with steroids, and central retinal artery occlusion). Prior authorization practice was changed: Prior Authorization not required for outpatient services effective 6/1/2022, although inpatient precertification/preauthorization remains required. (See Parts 2 and 3 for coding and application details.)

Medically-Necessary Criteria

Systemic hyperbaric oxygen therapy (HBOT) is considered medically necessary when ANY of the following indications are met:

ANY of the following

Non-healing diabetic lower‑extremity wound
- Individual has type I or type II diabetes and a lower‑extremity wound that is due to diabetes.
- Wound is classified as Wagner grade>= 3
- No measurable signs of healing after an adequate course of standard wound therapy for>= 30 days
Decompression sickness
Acute traumatic ischemia (e.g., crush injuries, reperfusion injury, compartment syndrome)
Gas embolism, acute
Acute carbon monoxide poisoning
Cyanide poisoning, acute
Soft‑tissue radiation necrosis (including radiation enteritis, cystitis, proctitis) and osteoradionecrosis
Gas gangrene (i.e., clostridial myonecrosis)
Pre‑ and post‑treatment for individuals undergoing dental surgery (non‑implant‑related) of an irradiated jaw
Profound anemia with exceptional blood loss when transfusion is impossible or must be delayed
Compromised skin flaps or grafts
Chronic refractory osteomyelitis
Progressive necrotizing soft tissue infections
Idiopathic sudden sensorineural hearing loss (SSNHL)
- HBOT combined with steroid therapy as salvage treatment
- Initiation of combined HBOT and steroid salvage therapy within<= 1 month
  Considered medically necessary when used as salvage within 1 month of symptom onset.
Central retinal artery occlusion

title':"Medically Necessary Indications"}

Investigational / Not Medically Necessary Indications

Systemic hyperbaric oxygen pressurization is INVESTIGATIONAL in the treatment of the following conditions:

ANY of the following

Topical hyperbaric oxygen therapy (not covered; investigational)
Topical HBOT is investigational per policy
Acute peripheral arterial insufficiency (outside of other listed medically necessary indications involving arterial insufficiency)
Acute ischemic stroke
Acute coronary syndromes and as an adjunct to coronary interventions (including PCI and cardiopulmonary bypass)

Evidence-based Coverage Conclusions

Evidence conclusions: systematic reviews and RCTs support sufficiency of evidence for improved net health outcomes with systemic HBOT in diabetic lower-extremity ulcers (higher healing rates and two meta-analyses showing fewer major amputations) and for radionecrosis/osteoradionecrosis. For many other indications the evidence is mixed or insufficient (including numerous acute and chronic conditions listed as investigational). Adverse events are uncommon but present, with an estimated overall adverse event rate of approximately 0.4%, primarily barotrauma and oxygen toxicity.

Coding

Covered CPTCPTCovered

99183

Physician attendance and supervision of hyperbaric oxygen therapy per session

Covered HCPCSHCPCSCovered

G0277

Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

Medically necessary ICD-10 diagnosesICD-10Covered

A48.0	Gas gangrene
D62	Acute posthemorrhagic anemia
E08.52	Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
E09.52	Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.51	Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E10.52	Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.59	Type 1 diabetes mellitus with other circulatory complications
E10.621	Type 1 diabetes mellitus with foot ulcer
E10.622	Type 1 diabetes mellitus with other skin ulcer
E10.628	Type 1 diabetes mellitus with other skin complications

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ICD-10-CM diagnosis codes referenced in this partICD-10

I70.231	Atherosclerosis of native arteries of right leg with ulceration of thigh
I70.232	Atherosclerosis of native arteries of right leg with ulceration of calf
I70.233	Atherosclerosis of native arteries of right leg with ulceration of ankle
I70.234	Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot
I70.235	Atherosclerosis of native arteries of right leg with ulceration of other part of foot
I70.238	Atherosclerosis of native arteries of right leg with ulceration of other part of lower leg
I70.239	Atherosclerosis of native arteries of right leg with ulceration of unspecified site
I70.241	Atherosclerosis of native arteries of left leg with ulceration of thigh
I70.242	Atherosclerosis of native arteries of left leg with ulceration of calf
I70.243	Atherosclerosis of native arteries of left leg with ulceration of ankle

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Referenced external coverage authoritymixed

CMS NCD 20.29

Medicare National Coverage Determination related to hyperbaric oxygen therapy

Billing Rule

Billing and Documentation Rules

Provider actions: The listed ICD-10 diagnosis codes must be submitted with CPT/HCPCS procedure codes when medical necessity criteria are met; use current industry-standard codes and modifiers. Clinical evidence summary required for coverage decisions. Prior authorization requirement: inpatient services require precertification/preauthorization; outpatient prior authorization requirements changed — verify product-specific rules at time of service.

Submit the applicable ICD-10 diagnosis codes with CPT/HCPCS procedure codes (e.g., 99183, G0277).
Follow the current policy coding section and use up-to-date industry-standard codes and modifiers for accurate billing.
Provide a clinical evidence summary when requested to support coverage decisions.
Prior authorization: inpatient hyperbaric services require precertification/preauthorization. Outpatient prior authorization requirements have changed by product — verify member's product rules before scheduling.

Provider Actions & Authorization

Prior Authorization

Precertification/Preauthorization required for inpatient services

Precertification/preauthorization is required for services performed inpatient. Outpatient services have different authorization rules (see outpatient guidance).

Prior Authorization

Outpatient prior authorization guidance (Commercial Managed Care/HMO/POS/PPO/Indemnity)

For outpatient services provided to Commercial Managed Care (HMO and POS), Commercial PPO, and Indemnity members: prior authorization is not required.

Effective 6/1/2022: prior authorization not required for outpatient services where specified.
Reference policy revision entries for authorization effective dates and operational changes.

Background & Definitions

Background: This policy distinguishes systemic versus topical HBOT and defines systemic HBOT indications as medically necessary or investigational based on evidence. Systemic HBOT is delivered in monoplace or multiplace chambers at pressures typically between 1.5 and 3.0 atmospheres. The policy specifically references combination therapy where relevant (for example, HBOT combined with steroid therapy for idiopathic sudden sensorineural hearing loss as a salvage therapy within the specified time window). The Wagner wound classification (Grades 0–5) is used to define wound severity for diabetic lower-extremity wound coverage (requiring Wagner grade >= 3 among other criteria).

Term	Definition
Wagner classification	Grades 0–5 describing severity of diabetic foot ulcers: Grade 0 = no open lesion; Grade 1 = superficial ulcer without penetration to deeper layers; Grade 2 = ulcer penetrates to tendon, bone, or joint; Grade 3 = lesion penetrated deeper than grade 2 with abscess, osteomyelitis, pyarthrosis, plantar space abscess, or infection of tendon/tendon sheaths; Grade 4 = wet or dry gangrene in the toes or forefoot; Grade 5 = gangrene involves the whole foot or such extensive involvement that no local procedures are possible and below‑knee amputation is indicated.
Topical HBOT	Delivery of 100% oxygen directly to an open, moist wound at a pressure slightly higher than atmospheric pressure using an appliance enclosing the wound area; intended to increase local tissue oxygen tension and promote wound healing (devices may enclose an extremity and use an oxygen source; may be disposable and used at home by trained patients).
Systemic HBOT	Patient entirely enclosed in a pressure chamber and breathes oxygen at pressures greater than 1 atmosphere; relies on systemic circulation to deliver highly oxygenated blood to target sites; delivered in monoplace (pressurized with pure O2) or multiplace (pressurized with compressed air with O2 by mask/head tent/endotracheal tube) chambers.
Barotrauma	Pressure‑related injury to closed air‑filled cavities (eg, ears, sinuses, teeth, lungs) causing pain or swelling during pressurization/depressurization; adverse events from the pressure effect of HBOT.
Oxygen toxicity	Adverse effects from high oxygen exposure affecting pulmonary, neurologic, or ophthalmologic systems (pulmonary: cough, substernal burning, dyspnea; neurologic: tunnel vision, tinnitus, nausea, dizziness, seizures possible; ophthalmologic: retinopathy in neonates, cataract formation, transient myopic changes).

Revision History

2/2025MaterialLatest

Annual policy review; literature through June 7, 2024; treatment of necrotizing soft tissue infections, idiopathic sudden sensorineural hearing loss, and central retinal artery occlusion added to medically necessary statement; coding clarified; Effective 2/1/2025

11/1/2023Material

Policy revised to include coverage for treatment of compromised skin grafts and flaps as medically necessary; clarified coding information; Effective 11/1/2023

6/1/2022Material