CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Hyperbaric Oxygen Therapy (HBOT) Coverage Criteria

This policy governs medical coverage and clinical criteria for systemic and topical hyperbaric oxygen therapy for Blue Cross Blue Shield - Rhode Island members, including Medicare and commercial products, and describes when HBOT is considered medically necessary or not.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyHyperbaric Oxygen Therapy (HBOT) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 21, 2017

Next Review DateN/A

Key ActionObtain prior authorization for BlueCHiP for Medicare (recommended for Commercial) via the web-based tool before providing HBOT unless filing with a covered diagnosis listed in the medical criteria attachment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1.5-3.0Systemic HBOT pressure range (atm)

>=30 daysMinimum duration to define failed wound care

99183, G0277Medically necessary procedure codes

Not coveredTopical HBOT coverage

Coverage Criteria for Hyperbaric Oxygen Therapy

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Topical Hyperbaric Oxygen Therapy

Topical HBOT: Topical hyperbaric oxygen therapy is not covered/not medically necessary because clinical efficacy has not been established

Evidence primarily case series and limited RCT data; therefore topical HBOT and related topical device codes are considered not medically necessary

Systemic hyperbaric oxygen therapy (HBOT) is considered not medically necessary when used for conditions other than those specifically listed in this policy. Available studies and guideline summaries support systemic HBOT only for the indications enumerated in the policy (for example, nonhealing diabetic lower‑extremity wounds, acute traumatic ischemia, certain radiation injuries, osteoradionecrosis, gas gangrene, and profound anemia when transfusion is impossible or delayed). For conditions not specified, the evidence does not demonstrate improved relevant health outcomes and therefore systemic HBOT is not covered.

Topical hyperbaric oxygen therapy and devices intended for topical oxygen delivery are considered not medically necessary due to insufficient evidence of clinical efficacy. For both Blue CHiP for Medicare and commercial products the literature consists primarily of case series and case reports, with only a single small randomized controlled trial in diabetic foot ulcers that did not show a significant benefit; therefore topical HBOT and the listed topical oxygen device HCPCS codes are not covered.

Coding and Billing Guidance

Covered CPT/HCPCS CodesmixedCovered

99183	Physician attendance and supervision of hyperbaric oxygen therapy, per session
G0277	Hyperbaric oxygen under pressure full body chamber; per 30 minutes

Not medically necessary codesHCPCSNot Covered

E0446	Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories
A4575	Topical hyperbaric oxygen chamber, disposable

Failure of standard wound care — minimum duration without measurable healing

Minimum duration without measurable healingNo measurable signs of healing after a minimum of 30 consecutive days of treatment

Required addressed factorsDocumentation must show vascular status assessed and corrected if possible; nutritional status; glucose control if diabetic; debridement; infection control; maintenance of a clean, moist granulation bed with appropriate dressings; appropriate off‑loading

Prior authorization linkPrior authorization is required for BlueCHiP for Medicare and recommended for Commercial products via the online tool

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for BlueCHiP for Medicare. For Commercial products, prior authorization is recommended via the payer's web-based preauthorization tool for participating providers. No preauthorization is needed for claims filed with a covered diagnosis noted in the attachment in the medical criteria section.

Prior authorization required: BlueCHiP for Medicare
Prior authorization recommended: Commercial (use web-based tool)
No preauthorization needed when claim includes a covered diagnosis from the medical criteria attachment

Denial Risk

Failure of Standard Wound Care Prerequisite

Providers must document that the patient failed to respond to standard wound care prior to Hyperbaric Oxygen Therapy (HBOT). Failure to respond is defined as no measurable signs of healing after a minimum of 30 consecutive days of appropriate wound care.

Minimum 30 consecutive days of documented standard wound care with no measurable improvement
Documentation must describe the wound care provided and timeline

Documentation Required

Required Clinical Documentation for Wound Indications

When indicating failure of standard wound care, submit clinical documentation that all of the following have been assessed and addressed as applicable: vascular status (and correction of vascular problems in the affected limb if possible), nutritional status, glucose control (if diabetic), debridement to remove devitalized tissue, treatment of any infection, and maintenance of a clean, moist granulation bed with appropriate moist dressings and off-loading.

Assessment and correction of vascular status when possible
Nutritional status evaluation
Glucose control for diabetic patients
Debridement performed as needed
Treatment of any infection present
Maintenance of a clean, moist bed of granulation tissue with appropriate dressings and off‑loading

Billing Rule

Not Medically Necessary Codes

Topical oxygen delivery systems (E0446) and disposable topical hyperbaric oxygen chambers (A4575) are listed as not medically necessary and claims for these codes will be denied.

E0446 — Topical oxygen delivery system (not medically necessary)
A4575 — Topical hyperbaric oxygen chamber, disposable (not medically necessary)

Background

Hyperbaric oxygen therapy (HBOT) can be administered systemically or topically. Systemic HBOT involves the patient breathing 100% oxygen at increased pressures inside a hyperbaric chamber and relies on systemic circulation to deliver dissolved oxygen to tissues; evidence supports its use for a defined set of indications. Topical HBOT delivers oxygen directly to an open, moist wound within an appliance or chamber placed over the wound; the evidence base for topical delivery is limited (mostly case series and reports) and randomized data are inadequate to establish clinical benefit.

Definitions

Systemic HBOT — definition and typical pressure range

DefinitionAdministration of 100% oxygen with the patient enclosed in a hyperbaric chamber at pressures greater than 1 atmosphere (systemic delivery)

Typical pressure rangePressures between 1.5 and 3.0 atmospheres (atm)

Chamber typesMonoplace chambers are pressurized with pure oxygen; multiplace chambers are pressurized with compressed air with patients receiving oxygen via mask, head tent, or endotracheal tube

Topical hyperbaric oxygen therapy — definition and device description

DefinitionDelivery of 100% oxygen directly to an open, moist wound in an appliance at a pressure slightly above atmospheric pressure

Device descriptionAn appliance that encloses the wound area (frequently an extremity) plus a source of oxygen; conventional oxygen tanks may be used; appliances may be disposable and used outside supervised settings

Intended mechanismOxygen diffuses into the wound to increase local cellular oxygen tension to promote wound healing