Hyperbaric Oxygen Therapy (HBOT) coverage criteria
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This document defines Blue Cross Blue Shield of North Carolina's coverage policy for systemic and topical hyperbaric oxygen therapy (HBOT), describing covered indications, investigational uses, and supporting evidence for providers and members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Hyperbaric Oxygen Therapy
Covered systemic HBOT indications
Systemic hyperbaric oxygen therapy is covered when ANY of the following indications are met and medical necessity is established:
Documentation should include diabetes type, Wagner grade, and objective evidence of lack of healing after 30 days of standard wound therapy.
Evidence-based coverage considerations / indication-specific evidence
Evidence summaries and recent updates informing coverage decisions:
short-term symptomatic benefit only
single short-term unblinded RCT
limited RCTs with methodological concerns
Cochrane review negative
benefit accompanied by notable adverse events
coverage addition noted
Topical (local) hyperbaric oxygen therapy is considered investigational for all indications and is excluded from coverage by Blue Cross Blue Shield of North Carolina.
Historically, BCBSNC has listed several non-covered or investigational uses in prior policy updates; examples include topical hyperbaric oxygen therapy, autism spectrum disorders, early post-radiation treatment to reduce radiation side effects, bisphosphonate-related osteonecrosis of the jaw, motor dysfunction associated with stroke, vascular dementia, and other neurologic and miscellaneous conditions.
Hyperbaric oxygen therapy for any condition not specifically listed as a covered systemic indication in this policy is considered investigational (not medically necessary) and is not covered.
For several indication-specific applications of HBOT, the evidence is limited or mixed. Examples cited in the evidence summary include: migraine (short-term symptom relief within 45 minutes reported in pooled RCTs but insufficient longer-term data), herpes zoster (a single unblinded RCT with only 6-week outcomes), fibromyalgia (two small RCTs with methodological limitations and variable protocols), multiple sclerosis (Cochrane review found no significant benefit), and adjunctive use in cancer patients (systematic review reported tumor-control findings accompanied by significant adverse events and no survival benefit in a single RCT). For these indications the evidence is judged insufficient to demonstrate a net health outcome improvement.
Billing and Coding
Provider Actions, Documentation & Prior Authorization
Prior authorization / medical necessity required for systemic HBOT
Systemic HBOT requires that the medical necessity criteria in this policy are met prior to coverage; topical hyperbaric oxygen therapy is considered investigational and is not covered.
- Ensure the patient meets one of the listed covered indications and all indication-specific criteria before submitting for coverage.
Codes listed do not guarantee payment; records may be requested
Applicable service codes are listed in the policy for billing, but inclusion of a code does not guarantee reimbursement. BCBSNC may request medical records to determine medical necessity.
30-day adequate course of standard wound therapy required before HBOT
For non-healing diabetic lower-extremity wounds, an adequate course of standard wound therapy for 30 days with no measurable signs of healing is required before adding HBOT; the wound must also be Wagner grade 3 or higher.
- Document at least 30 days of standard wound care with objective lack of measurable healing.
- Confirm and document Wagner classification (grade 3 or higher) in the record.
Required documentation for diabetic lower‑extremity wounds
For diabetic lower-extremity wounds, documentation must show diabetes type (I or II), the wound classified by Wagner grade (grade 3 or higher), and objective evidence that the wound had no measurable signs of healing after 30 days of an adequate course of standard wound therapy.
- Include diabetes type (type I or II) in the record.
- Record Wagner grade and wound description (location, size, depth, presence of osteomyelitis/abscess if applicable).
- Document the 30-day standard therapy details and objective measures showing no measurable healing.
Medical records may be requested; letters alone may be insufficient
BCBSNC may request medical records to determine medical necessity; letters of support or explanation are often useful but are not sufficient unless they include all specific information needed for the medical necessity determination.
- Provide complete medical records when requested; do not rely solely on letters unless they contain all required clinical details.
Topical HBOT is investigational and not covered
Topical (local) hyperbaric oxygen therapy is considered investigational for all indications and requests for topical HBOT will be denied.
- Do not submit topical HBOT for coverage—such requests are excluded and will be denied as investigational.
Non‑listed indications are at risk for denial
Requests for HBOT for indications not listed among the policy’s covered conditions are at risk for denial as investigational.
- Confirm the indication is one of the listed covered conditions before requesting authorization.
- If the indication is not listed, expect a denial unless sufficient evidence in the medical record supports medical necessity within policy criteria.
Code inclusion does not guarantee payment; records may be requested
Inclusion of a service code in the billing/coding section does not guarantee reimbursement; BCBSNC may request medical records to determine medical necessity and payment eligibility.
- Do not assume payment solely because a code appears in the policy—be prepared to submit requested medical records for review.
Background and Scope
Hyperbaric oxygen therapy can be delivered as systemic therapy — the patient breathes oxygen inside a pressurized whole‑body chamber (>1 atmosphere; monoplace or multiplace chambers) — or as topical (local) therapy, which delivers 100% oxygen directly to an open wound via an enclosure at slightly above atmospheric pressure. Systemic HBOT increases oxygen delivery through the circulation to support wound healing and treat selected systemic conditions; topical HBOT targets oxygen at the wound surface but, as noted in this policy, has not demonstrated sufficient evidence of benefit and is considered investigational.
Definitions
Revision History
Original policy established (Hyperbaric Oxygen Pressurization).
Policy reaffirmed and list of experimental/investigational indications added.
Policy reaffirmed.
Policy revised.
Combined local and national policies; added indication for full mouth extraction after head/neck radiation and prophylactic HBOT diagnosis after radiation therapy.
Policy reaffirmed.
Topical hyperbaric oxygen therapy explicitly stated as investigational; reaffirmed by MPAG.
Policy reformatted and procedural description changed; medical term definitions added.
Policy reviewed and indications changed per TEC review (10/99).
Indications changed per BCBSA/TEC and consultant recommendations; compromised skin grafts/flaps and acute thermal burns listed as non-covered.
Medical Policy Advisory Group activity and system coding changes noted.
MPAG review with no changes to criteria; later coding format change in 2002.
Specialty Matched Consultant Advisory Panel review; new sources added but no policy changes (reaffirmed).
Format edits made to covered and not covered sections.
Benefits Application and Billing/Coding sections updated for consistency.
Specialty Matched Consultant Advisory Panel review (3/10/05); no changes to policy criteria; references updated.
Policy name changed from 'Hyperbaric Oxygen Pressurization' to 'Hyperbaric Oxygen Therapy' and description updated.
MPAG review; no change to policy statement; references updated.
MPAG review; no change to policy statement; references updated.
Description and Policy Guidelines sections updated; MPAG review with no change to policy statement.
References and Policy Guideline section updated; MPAG review with no change to policy statement.
Policy Guidelines and Description of Service updated; references added; no change to policy statement.
MPAG review and references updated; no change to policy statement.
References updated; MPAG and Medical Director reviews completed in 10/2021; no change to policy statement.
Minor updates to policy guidelines and references; MPAG and Medical Director reviews completed in 10/2022 with no change to policy statement.
Regulatory status updated and term 'patients' changed to 'individuals' in coverage criteria; references updated; MPAG and Medical Director reviews completed in 10/2023.
'When covered' section updated to add avascular necrosis (aseptic osteonecrosis) as an indication for coverage based on updated UHMS guidelines; references and policy guidelines updated.
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