Hyperbaric Oxygenation Therapy
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This policy governs coverage and prior approval requirements for hyperbaric oxygen therapy (HBO) for NC Medicaid beneficiaries, specifying covered indications, limitations, and EPSDT exceptions for beneficiaries under 21.
No material clinical or coverage changes in this revision.
Coverage Criteria for Hyperbaric Oxygen Therapy
General Coverage Criteria
Medicaid covers HBO when medically necessary and all of the following are met:
From Section 3.1(a).
From Section 3.1(b).
From Section 3.1(c).
Specific Indications Covered
HBO is covered when the beneficiary has one of the following indications (adjunctive use and other conditions specified where noted):
See Sections 3.2.1–3.2.2; adjunctive use noted where specified.
Wound Therapy Continuation Criteria
Conditions for continuation of HBO for diabetic wounds:
Wagner Grade III+ requirement and 30-day standard wound therapy failure described in Section 3.2.1; Amended Date: August 15, 2023.
Use of hyperbaric oxygenation (HBO) for indications outside those specifically listed in Section 3.2 is not covered. In particular, HBO is not approved for the treatment of multiple sclerosis or for brain injury conditions referenced in the policy (this grouping includes autism, cerebral palsy, and stroke) due to lack of evidence-based medicine supporting these uses.
Medicaid does not cover Hyperbaric Oxygenation Therapy for the following conditions: acute cerebral edema; acute or chronic cerebral vascular insufficiency; acute thermal and chemical pulmonary damage (for example, smoke inhalation with pulmonary insufficiency); aerobic septicemia; anaerobic septicemia and infections other than clostridial; arthritic diseases; cardiogenic shock; chronic peripheral vascular insufficiency (except as specifically noted in Subsection 3.2); 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 causes of chronic brain syndrome (such as Pick's disease, Alzheimer's disease, Korsakoff's disease); organ storage; organ transplantation; pulmonary emphysema; senility; sickle cell crisis; thermal skin burns; systemic aerobic infection; tetanus; and traumatic brain injury.
This policy has been updated to align with current template language and administrative changes noted in the revision history, including adjustments related to the transition of the North Carolina Health Choice Program into Medicaid. Refer to the Revision Information for specific section updates and amendment dates.
When no specific CPT or HCPCS code exists for a procedure, providers shall report the service using the appropriate unlisted procedure or service code per CPT/HCPCS guidance. Providers must follow the current coding edition's instructions for unlisted codes and submit any required documentation or Special Report(s) as specified by the coding system and payer.
Services that are experimental or investigational, or those provided as part of a clinical trial, are not covered by Medicaid under this policy.
Topical application of oxygen does not meet the policy definition of hyperbaric oxygen therapy and is not covered. Additionally, HBO is not covered as a replacement therapy for other standard, successful therapeutic measures.
Coding and Claim Submission
| CMS-1500 | Professional claim form/837P transaction |
| UB-04 | Institutional claim form/837I transaction |
| A42.0 | ICD-10-CM code listed in Attachment A mappings |
| A18.01 | ICD-10-CM code listed in Attachment A mappings |
| M87.343 | ICD-10-CM/PCS code mapping entries shown in Attachment A |
| M86.179 | ICD-10-CM code listed in mapping |
| M88.859 | ICD-10-CM code listed in mapping |
| M88.861 | Mapped PCS/ICD output in listing |
| S65.299A | ICD-10-CM code listed in mapping |
| S65.301A | Mapped PCS/ICD output in listing |
| M86.18 | ICD-10-CM code listed in mapping |
| M86.19 | ICD-10-CM code listed in mapping |
| M86.20 | ICD-10-CM code listed in mapping |
| M86.211 | ICD-10-CM code listed in mapping |
| M86.212 | ICD-10-CM code listed in mapping |
| M87.037 | listed mapping entries in attachment |
| S38.001A | mapped values appear in attachment |
| M87.142 | example mapping entry; referenced with amendment date |
| S68.122D | mapped in attachment |
| I70.232 | Table A ICD-10-Code(s.) — must be billed with diabetic diagnosis codes |
| I70.233 | Table A ICD-10-Code(s.) — must be billed with diabetic diagnosis codes |
| I70.239 | Table A ICD-10-Code(s.) — has associated L97.* codes in Table B |
| L97.801 | Example Table B diabetic/ulcer codes referenced to be billed with Table A codes |
| L97.829 | Example Table B diabetic/ulcer codes |
| RC413 | |
| 5A05121 | Extracorporeal Hyperbaric Oxygenation, Intermittent |
Prior Authorization, Documentation, and Billing Actions
Obtain prior approval before HBO (EPSDT exception does not waive PA)
Prior approval is required for Hyperbaric Oxygenation Therapy and must be obtained before rendering the service; EPSDT does not remove prior approval requirements for beneficiaries under 21 years of age.
Initial PA limited to 30 days; obtain additional PA for continuation
Submit a prior approval request before initiating HBO; initial authorization is granted for a 30-calendar-day period and any treatment beyond 30 days requires a second prior approval.
Use NCTracks and DHHS Utilization Review Contractor procedures for PA
Follow NC Medicaid prior approval procedures by submitting PA requests and supporting records to the DHHS Utilization Review Contractor and consult the NCTracks Provider Claims and Billing Assistance Guide and Medicaid bulletins where applicable.
- NCTracks Provider Claims and Billing Assistance Guide: https://www.nctracks.nc.gov/content/public/providers/providermanuals.html
- EPSDT provider page: https://medicaid.ncdhhs.gov/
Reference: NC Medicaid Policy 1A-8 (Attachment A) and amendment date
This appendix is part of NC Medicaid Hyperbaric Oxygenation Therapy (Medicaid Clinical Coverage Policy No: 1A-8, Amended August 15, 2023); follow the policy's prior authorization requirements as specified in the main policy text.
Bill using Attachment A ICD-10-CM/PCS mappings and Table A/Table B pairings
When submitting claims, use the ICD-10-CM and ICD-10-PCS codes and the specific code mappings provided in Attachment A; Table A diagnosis codes listed in the attachment must be billed together with the corresponding diabetic diagnosis codes from Table B.
Report required professional/facility/PCS codes and check payer systems
Report the listed professional, facility and ICD-10-PCS codes when applicable and verify any payer-specific prior authorization requirements with NC Medicaid state-plan or payer systems.
- Facility ICD-10-PCS example: 5A05121 (Extracorporeal Hyperbaric Oxygenation, Intermittent)
- Professional example code listed in policy attachments
Require ≥30 days failed standard wound therapy before HBO for diabetic wounds
For diabetic lower-extremity wounds, HBO is covered only after failure of an adequate course of standard wound therapy (failure defined as no measurable signs of healing for at least 30 consecutive days); continuation criteria apply and wounds must be evaluated at least every 30 days.
- Standard wound care components are listed in Section 3.2.1 and must be continued while HBO is provided.
- Continued HBO is not covered if measurable signs of healing are not demonstrated within any 30-day treatment period.
Initial authorization = 30 calendar days; secure additional PA to continue
Initial prior authorization is limited to a 30-calendar-day period; obtain and submit a subsequent prior approval request to continue treatment beyond that initial 30 days.
No step therapy requirements stated
No step therapy language is specified in these sections of the policy.
Document medical necessity and EPSDT-specific justification for beneficiaries <21
Document medical necessity for all PA requests; for beneficiaries under 21, EPSDT documentation must demonstrate that the service corrects or ameliorates the beneficiary's condition. For diabetic wounds include documentation of failure of at least 30 consecutive days of standard wound therapy and wound evaluations at least every 30 days during HBO.
- Include diagnoses, date of onset, conventional treatment history with durations and outcomes, and a treatment plan including duration.
- In urgent situations, submit PA within five calendar days and mark requests 'urgent' so authorization may begin on the first date of treatment if criteria are met.
Submit PA request with supporting health records showing Subsection 3.2 criteria are met
Submit the completed prior approval request plus all supporting health records demonstrating the specific criteria in Subsection 3.2 are met; include beneficiary diagnoses, date of onset, conventional treatment history (with durations and outcomes), and a treatment plan including proposed duration.
- PA requests must indicate acceptance of the case by the HBO facility medical director (or designee).
- Urgent PAs: submit within five calendar days of treatment initiation; if received within five days authorization may begin on first treatment date.
Report ICD-10 codes at highest specificity and use current edition
Report ICD-10-CM and ICD-10-PCS codes to the highest level of specificity that supports medical necessity and use the current ICD-10 edition in effect at the time of service.
Use Attachment A ICD-10-CM/PCS code pairings on claims
When submitting claims for HBO, use the ICD-10-CM and PCS code combinations listed in Attachment A of this policy (Attachment A contains the specific pairings and mappings used by NC Medicaid).
Bill Table A diagnosis codes with specified Table B diabetic codes
Table A diagnosis codes listed in Attachment A must be billed together with the appropriate diabetic diagnosis codes from Table B as specified in the attachment; failure to bill these paired codes may result in claim processing issues or denials.
Follow CPT/HCPCS unlisted-code reporting and submit Special Report
If no specific CPT or HCPCS code exists for the service provided, comply with CPT/HCPCS instructions for unlisted procedure/service codes and submit the required Special Report per the current code editions.
- Follow Instructions for Use of the CPT Codebook and HCPCS unlisted reporting guidance and include a Special Report as required.
Denial risk: beneficiary ineligible, criteria unmet, duplicate service, or experimental treatment
Claims may be denied if the beneficiary does not meet eligibility in Section 2.0, does not meet the criteria in Section 3.0, the service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial.
General denial triggers: eligibility, coverage criteria, duplication, experimental services
Coverage is denied when the beneficiary does not meet eligibility requirements in Section 2.0 or the criteria in Section 3.0, when the procedure duplicates another provider's service, or when the service is experimental/investigational or part of a clinical trial.
Bill institutional claims per National Uniform Billing and coding guidelines
Institutional claims must be billed according to the National Uniform Billing Guidelines and all claims must comply with National Coding Guidelines; failure to follow these billing standards may result in claim denial or noncompliance findings.
Coding mismatch risk: use Attachment A pairings to avoid denial
Claims may be denied or miscoded if diagnoses or procedure codes submitted do not match the specified ICD-10-CM/PCS pairings listed in Attachment A.
Risk of denial if Table A codes are not billed with Table B diabetic codes
Failure to bill Table A ICD-10-CM diagnosis codes together with the appropriate diabetic diagnosis codes from Table B, as specified in Attachment A, may result in claim processing issues, delays, or denials.
Use the most specific billing codes available
Report the most specific billing code that accurately and completely describes the procedure, product, or service provided; failure to use the most specific code may result in claim processing issues or denials.
Background
Hyperbaric oxygenation therapy (HBO) involves exposing the whole body to 100% oxygen at pressures greater than 1 atmosphere absolute (ATA) in a pressurized monoplace or multiplace chamber following accepted clinical protocols. HBO is used as an adjunctive treatment for specific, evidence-supported indications where increased tissue oxygenation can assist healing or treat hypoxic/ischemic conditions.
Definitions and Technical Requirements
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