Currentblue cross blue shield - south dakotaPolicy N/A

Hyperbaric Oxygen Therapy (Systemic HBOT and Topical HBOT/THOT)

This policy governs coverage and medical necessity considerations for systemic hyperbaric oxygen therapy and topical hyperbaric oxygen therapy (THOT) for Wellmark/Blue Cross Blue Shield - South Dakota members.

Policy Summary

Payerblue cross blue shield - south dakota

PolicyHyperbaric Oxygen Therapy (Systemic HBOT and Topical HBOT/THOT)

Policy CodePolicy N/A

Change TypeAnnual review — no material changes

Effective DateSep 1, 1999

Next Review DateN/A

Key ActionObtain prior authorization and document indication, prior therapies, HBOT regimen, and follow-up per InterQual criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Prior approvalAuthorization requirement for HBOT

InvestigationalTopical HBOT coverage stance

Investigational (many)Systemic HBOT coverage stance

1.5–3.0 atmTypical HBOT pressures

0.4%Adverse event rate

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99183, G0277, A4575Key codes

Coverage Criteria and Evidence Conclusions

Autism Spectrum Disorder — Evidence and Follow-Up

Systemic hyperbaric oxygen therapy (HBOT) for autism spectrum disorder (ASD): evidence summary, key trial findings, limitations, and required follow-up to demonstrate efficacy.

All of the following summarize the evidence base and follow-up considerations for systemic HBOT in individuals with autism spectrum disorder (ASD).

A Cochrane review (Xiong et al., 2016) identified a single randomized controlled trial (Sampanthavivat et al., 2012) that met eligibility criteria. That trial randomized children with ASD to 20 one-hour sessions of HBOT versus sham air (n=30 per group). The trial was assessed as low-quality evidence by GRADE. There were no statistically significant differences between HBOT and sham for the primary outcomes (Autism Treatment Evaluation Checklist and Clinical Global Impression scores) assessed by clinicians and parents.

A small controlled trial (Rizzato et al., 2018) also evaluated HBOT in children with autism and reported improvements over time in both HBOT and control groups; investigators concluded their results do not support the use of HBOT in children with autism.

A later systematic review and meta-analysis (Tu et al., 2025) identified 17 studies (n=890) and reported a pooled effect suggesting potential reduction in core autism symptoms (SMD = -0.66, 95% CI -1.04 to -0.28). However, substantial limitations — including poor methodological quality of many included studies, high heterogeneity, and study design limitations — preclude drawing strong conclusions about efficacy.

Across randomized trials, limitations include small sample sizes, short duration of follow-up (typical trial follow-up was about 10 weeks), variable HBOT protocols (pressures, session counts, duration), and risk of bias related to blinding and outcome assessment. These methodologic weaknesses increase the likelihood that observed effects may reflect placebo or bias rather than true treatment effects.

Minimum follow-up considered necessary to demonstrate meaningful and durable benefit in ASD is at least 6 months after treatment completion to assess change in core symptoms and functional outcomes.

Current evidence does not demonstrate consistent, high-quality benefit of systemic HBOT for ASD. Well-designed, adequately powered, randomized, double-blind (sham-controlled) trials with standardized HBOT protocols and at least 6 months of follow-up are needed to determine whether HBOT improves clinically meaningful outcomes in ASD.

Coding, Treatment Parameters, and Follow-up Expectations

Topical HBOT HCPCSHCPCS

A4575

Disposable topical hyperbaric oxygen appliance (describes a topical HBOT device)

Prior authorization—affected codesmixed

affected codes

Policy references 'affected codes' for prior authorization (specific codes not listed in this chunk)

Topical HBOT HCPCSHCPCS

A4575

Disposable topical hyperbaric oxygen appliance

Provider CPT CodeCPTCovered

99183

Physician or other qualified health care professional, attendance, and supervision of hyperbaric oxygen chamber, per session.

Facility/Procedure HCPCSHCPCSCovered

G0277

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

Device HCPCSHCPCSCovered

A4575

Topical hyperbaric oxygen chamber, disposable.

inv-61: HBOT treatment pressure

DefinitionSystemic HBOT: treatment breathing 100% oxygen at pressures >1.4 atmosphere absolute (typical clinical range 1.5–3.0 ATA)

inv-62: UHMS recommended pressures and session counts — example regimens

Diabetic lower‑extremity wounds2.0–2.5 ATA, daily; outpatient course typically 30 sessions (may require up to 40); reevaluate at 30‑day intervals

Radiation necrosis2.0–2.5 ATA for 40–60 treatments; review after 60 treatments

Chronic refractory osteomyelitis2.0–3.0 ATA, once daily 5–7 days/week for 90–120 minutes; typically 20–40 sessions (up to 60 in some cases)

Prior Authorization, Documentation, and Operational Requirements

Prior Authorization

Prior Approval and Authorization Drivers

Prior approval is required for systemic HBOT. Refer to the Wellmark Authorization Table for InterQual® clinical coverage criteria; failure to obtain prior approval may result in claim denial.

Prior approval required for systemic HBOT per Wellmark Authorization Table and InterQual® criteria.
Authorization may be driven by CMS NCD and UHMS/ACHM indications; requests outside these drivers warrant stronger justification.

Prior Authorization

Prior Authorization Recommended for ACS and Stroke

Prior authorization is recommended when HBOT is requested for acute coronary syndromes (ACS) or acute ischemic stroke because evidence is limited and variable; reviewers will expect detailed clinical justification and plans for longitudinal follow-up.

Prior authorization recommended for ACS and acute ischemic stroke due to limited/heterogeneous evidence.
Document why HBOT is being requested as an adjunct to standard ACS or stroke care and the planned follow-up interval (minimum 6 months–1 year as applicable).

Definitions, Background, and Therapy Characteristics

Hyperbaric oxygen therapy involves breathing 100% oxygen at elevated pressures; systemic HBOT is typically administered at pressures in the range of 1.5–3.0 atmospheres absolute (ATA) in a hyperbaric chamber to increase systemic tissue oxygen delivery.

inv-133: Systemic Hyperbaric Oxygen Therapy (HBOT) — definition and delivery context

Systemic HBOT — definitionWhole‑body exposure in a monoplace or multiplace hard‑sided chamber breathing 100% oxygen at pressures >1.4 ATA; relies on systemic circulation to deliver oxygen to tissues

Delivery contextsAdministered in monoplace (pure O2) or multiplace (air‑pressurized with oxygen delivery via mask/tent) chambers meeting safety standards

inv-134: Topical Hyperbaric Oxygen Therapy (THOT) — definition and HCPCS references

Topical HBOT (THOT) — definitionLocalized application of 100% oxygen to an isolated body part using an appliance that creates a pressurized chamber around the wound; HCPCS A4575 describes a disposable topical HBOT appliance

References, Guidelines, and Evidence Sources

Policy conclusions and recommendations were informed by multiple authoritative sources, including the Undersea & Hyperbaric Medical Society (UHMS) position/indications manual, American College of Hyperbaric Medicine guidance, Cochrane and other systematic reviews, and health technology assessments (eg, Hayes) cited in the references.

The Undersea & Hyperbaric Medical Society (UHMS) indications manual and position statements were used as key references for accepted indications and suggested treatment regimens in this policy.

Multiple Cochrane systematic reviews and other systematic reviews are cited throughout the document and form the primary evidence base informing the policy’s coverage conclusions and recommendations.

The Centers for Medicare & Medicaid Services National Coverage Determination for Hyperbaric Oxygen Therapy is cited among referenced guidance and may inform coverage decisions and prior authorization criteria.

Hayes health technology assessments and evidence reviews are listed among the references and were considered when evaluating the evidence for multiple indications.

Evidence‑based coverage conclusions in the policy draw on randomized trials and systematic reviews summarized in the references; where trials are few, small, heterogeneous, or show inconsistent results, the policy concludes evidence is insufficient for routine coverage and indicates areas needing additional high‑quality RCTs.

The policy’s evidence‑based considerations and recommended approaches reference guideline excerpts and systematic reviews (eg, UHMS guidance and Cochrane reviews) to inform when HBOT may be appropriate and when evidence gaps justify investigational or noncoverage stances.

Policy Revision History

2025-11annual_reviewLatest

Annual review and policy renewal completed (policy renewed).

2024-09annual_review

Annual review and policy revision completed.

2024-03annual_review

Policy Summary

Payerblue cross blue shield - south dakota

PolicyHyperbaric Oxygen Therapy (Systemic HBOT and Topical HBOT/THOT)

Policy CodePolicy N/A

Change TypeAnnual review — no material changes

Effective DateSep 1, 1999

Next Review DateN/A

Key ActionObtain prior authorization and document indication, prior therapies, HBOT regimen, and follow-up per InterQual criteria.

SourceLink

On This Page

Central retinal artery occlusion (CRAO)Recommend 2.0–2.8 ATA (or US Navy Table 6); treat twice daily to clinical plateau (typically <1 week) plus 3 days

inv-63: Minimum follow-up duration — ACS and stroke

Acute coronary syndromeMinimum recommended follow‑up to demonstrate efficacy: at least 1 year

Acute ischemic strokeMinimum recommended follow‑up to demonstrate efficacy: 6 months to 1 year or more

RationaleLonger‑term follow‑up provides opportunity to assess survival, functional status and cardiac outcomes

inv-64: Minimum follow-up to demonstrate efficacy for TBI

Traumatic brain injury (TBI)Minimum follow‑up to demonstrate efficacy: at least 1 year

Outcome measuresUse validated scales (e.g., GCS, GOS, RPQ, PCL) with baseline and longitudinal assessment

inv-65: Minimum follow-up durations — IBD, DOMS, ASD

Inflammatory bowel disease (IBD)Minimum follow‑up to demonstrate efficacy: ≥1 year

Delayed‑onset muscle soreness (DOMS)Minimum follow‑up to demonstrate efficacy: ≥1 month

Autism spectrum disorder (ASD)Minimum follow‑up to demonstrate efficacy: ≥6 months

inv-66: Minimum follow-up duration — ASD, CP

Autism spectrum disorder (ASD)Minimum follow‑up to demonstrate efficacy: ≥6 months

Cerebral palsy (CP)Minimum follow‑up to demonstrate efficacy: ≥1 year

DocumentationProvide baseline symptom and functional measures and planned follow‑up per indication

inv-67: Typical trial regimen — CP trials

Typical CP trial regimen40 HBOT sessions delivered over ~2 months (commonly used regimen in CP randomized trials)

Dosing examplesExamples used in trials include 100% oxygen at ~1.5–1.75 ATA for session durations as specified per study

inv-68: Minimum follow-up to demonstrate efficacy — general guidance

General guidance for chronic/subjective conditionsMinimum follow‑up to demonstrate efficacy: ≥1 year for many indications lacking prompt objective endpoints

RationaleLonger follow‑up captures sustained functional and clinical outcome differences beyond short‑term effects

inv-69: Minimum follow-up duration — migraine, herpes zoster, fibromyalgia

MigraineMinimum follow‑up to demonstrate efficacy: ≥1 month (immediate relief within 45 minutes reported in trials)

Herpes zosterMinimum follow‑up to demonstrate efficacy: ≥1 year (short‑term benefit reported in one RCT but long‑term unclear)

FibromyalgiaMinimum follow‑up to demonstrate efficacy: ≥1 year

inv-70: Minimum follow-up to demonstrate efficacy — chronic/subjective conditions

Chronic/subjective indicationsMinimum follow‑up to demonstrate efficacy: generally ≥1 year (policy emphasizes 1 year for conditions like fibromyalgia and MS)

ImplicationPrior authorization should require planned longitudinal outcome assessment when requested for these indications

inv-71: Follow-up duration — systemic HBOT in cancer; THOT follow-up ranges

Systemic HBOT in cancerMinimum follow‑up to demonstrate efficacy: at least 1 year

Topical HBOT (THOT) follow‑upTHOT follow‑up varies by wound site and severity and can range from months up to 1 year

DocumentationPrior authorization should include prior treatments and planned follow‑up consistent with indication (eg, radiotherapy/chemotherapy context)

inv-72: Wound improvement trial period — diabetic foot ulcers

Diabetic foot ulcer (Wagner Grade ≥3)Require ~30 days of standard care without significant improvement before adding HBOT (reevaluate after 30 days)

UHMS recommendationUHMS suggests considering HBOT for Wagner Grade ≥3 ulcers not improving after 30 days to reduce major amputation risk

Prior Authorization

Prior Authorization for Non‑Standard/Off‑Label Indications and FDA Warning

Requests for non-standard or off-label HBOT indications require prior authorization with clear clinical rationale and supporting evidence. The FDA warns that safety/effectiveness have not been established for many off-label uses; reliance on off‑label claims alone is insufficient.

Prior authorization recommended for non-standard indications (e.g., autism, dementia, MS, Bell’s palsy) — provide study-level evidence or contemporaneous clinical rationale.
FDA 2013 warning: many HBOT uses are not FDA-cleared; off-label use may endanger patients and should not replace proven therapies.

Documentation Required

Clinical Justification and Prior Authorization Requirements

Clinical justification must accompany prior authorization requests. Submit indication-specific diagnosis, prior and concurrent therapies, rationale for HBOT, treatment regimen, and planned objective outcome measures and follow-up schedule.

Include documented indication and relevant ICD-10 diagnosis.
Describe prior/concurrent therapies (medications, surgeries, rehabilitation, behavioral therapies) and why standard treatments are inadequate or exhausted.
Provide the proposed HBOT protocol (pressure, duration, number and frequency of sessions) and anticipated treatment setting.
Describe planned baseline and longitudinal outcome measures (e.g., NIH Stroke Scale, GCS, GOS, EDSS, validated QOL tools) and follow-up duration (see indication-specific minimums).

Documentation Required

Baseline and Longitudinal Follow‑up Documentation Required

Require baseline and longitudinal outcome documentation tailored to the indication. For subjective or slowly changing conditions, at least 1 year of follow-up is typically expected; other minimums include 6 months for some stroke/TBI outcomes and 1 month for DOMS.

Baseline objective measures (e.g., GCS, NIH Stroke Scale, EDSS, Gross Motor Function Measure) must be submitted.
Minimum follow-up expectations: typically 1 year for many neurologic and chronic conditions (TBI, fibromyalgia, MS, cancer-related outcomes); 6 months for some post‑stroke outcomes; 1 month for delayed-onset muscle soreness.
For TBI and neurologic indications provide validated scales at baseline and at planned follow-up intervals.

Documentation Required

Required Clinical Documentation for Bell Palsy and Limited‑Evidence Indications

Provide indication‑specific documentation for Bell palsy and other indications with limited evidence. For Bell palsy, document symptom severity, prior steroid/antiviral treatment, timing since onset, and rationale for HBOT given lack of supportive RCT data.

Document prior treatments (e.g., steroids, antivirals) and timeline since symptom onset.
Explain objective measures and planned follow-up (3 months to 1 year as appropriate) given paucity of high-quality evidence.

Denial Risk

Insufficient Supportive Evidence and Denial Risk

Evidence is insufficient or inconsistent for many proposed HBOT indications (e.g., autism spectrum disorder, cerebral palsy, fibromyalgia, vascular dementia, idiopathic femoral head necrosis). Requests for coverage where evidence is weak should include trial-level data or strong contemporaneous clinical rationale; absent this, denial is possible.

ASD, CP, fibromyalgia, vascular dementia, femoral head necrosis: small trials, methodological limitations, or mixed results.
MS: systematic reviews and pooled RCT data have not demonstrated benefit — expect denials without compelling new evidence.

Denial Risk

Adverse Events May Trigger Denial or Restriction

Adverse events and safety concerns identified in the literature may affect authorization and coverage decisions. For example, HBOT given with radiotherapy has been associated with increased serious adverse events (radiation injury, seizures); treatments with notable safety signals require stronger justification and monitoring plans.

Document risk mitigation and monitoring plans when HBOT is combined with radiotherapy or in populations at higher AE risk.
Chamber- and protocol-related AEs (e.g., barotrauma, headache) should be tracked and reported as part of follow-up.

Billing Rule

Authorization and Coding Requirements — Use Appropriate Codes

Use appropriate billing and procedure codes on authorization requests and claims. Prior authorization and payment depend on correct CPT, HCPCS, revenue, and ICD coding; incorrect codes may result in denial or claim adjustment.

Common codes: CPT 99183 (attendance/supervision per session); HCPCS G0277 (full body chamber per 30‑minute interval); HCPCS A4575 (topical hyperbaric oxygen chamber, disposable).
Include relevant revenue and ICD-10 diagnosis codes and place of service (inpatient/outpatient/home) on requests.

Documentation Required

Topical HBOT (THOT) — Documentation and Prior Care Required

Topical HBOT (A4575) has limited and heterogeneous evidence. For THOT, document wound characteristics, prior conservative wound care, device/appliance details, treatment regimen, setting (home vs clinic), and planned follow‑up; follow-up may range from months to a year depending on wound severity.

Document prior conservative therapies (dressings, debridement, antibiotics) and wound severity.
Specify device model or disposable appliance (HCPCS A4575), regimen (session length/frequency), and whether therapy is home‑administered or supervised.

Note

Guideline and CMS NCD References Inform Authorization

Policy and coverage decisions reference clinical guideline sources (UHMS, ACHM) and CMS National Coverage Determination (NCD). Prior authorization determinations may be informed by these sources; cite guideline or NCD support in requests when applicable.

UHMS and ACHM indications and position statements commonly drive authorization expectations.
CMS NCD 20.29 is a referenced driver — align requests with NCD criteria when applicable.

Step Therapy

Adjunctive/Stepwise Use — Document Prior or Failed Standard Therapies

Adjunctive use of HBOT to standard therapies requires documentation that standard, conservative, or stepwise therapies were considered or tried. For wounds and many non‑oncologic indications, document a trial of conservative care before topical HBOT or systemic HBOT as adjunct.

For diabetic foot ulcers, UHMS suggests considering HBOT after ~30 days of standard care in Wagner Grade ≥3 ulcers — document standard care trial.
When proposing HBOT as adjunctive therapy (e.g., after surgery, rehabilitation, medications), describe prior treatments and rationale for adding HBOT.

Settings and devicesTHOT may be delivered in office, clinic, or at home using conventional oxygen tanks and disposable enclosures (example: AOTI HyperBox™)

inv-135: Systemic HBOT — monoplace or multiplace chamber definition and rationale

Monoplace vs multiplaceMonoplace chamber: patient fully enclosed and breathes pure oxygen; Multiplace: chamber pressurized with air and patient receives oxygen via mask/tent — both deliver systemic hyperoxia

RationaleSystemic circulation transports increased dissolved oxygen to target tissues in systemic HBOT

inv-136: Topical HBOT (THOT/Topical HBOT) — localized delivery description and appliance use

Topical HBOT deliveryTHOT delivers 100% oxygen directly to an open moist wound at slightly above atmospheric pressure using an appliance that encloses the wound area

Device codingDisposable topical HBOT appliance coded A4575

inv-137: HBOT dosing — example dosing from trials (ACS, fibromyalgia)

Acute coronary syndrome trial dosing exampleHBOT administered between 2–3 ATA for 30–120 minutes per session in ACS trials

Fibromyalgia trial dosing exampleEfrati et al.: 100% oxygen at 2.0 ATA, 90‑minute sessions, 40 sessions

inv-138: Per-protocol analysis — definition and relevance

Per‑protocol analysis — definitionAnalysis of outcomes based on treatment actually received rather than initial randomized assignment; may bias results by not preserving randomization

ContextNoted as a limitation in trials with crossovers (e.g., Freiberger et al. bisphosphonate jaw RCT)

inv-139: Systemic HBOT — administration examples

Systemic HBOT administration exampleExample regimen: 100% oxygen at 2.0 ATA, repeated sessions (eg, 40 sessions over 2 months used in some neurologic trials)

Session frequencyTypical trial schedules range from once daily to twice daily depending on indication and urgency

inv-140: Relevant outcomes — key outcomes to assess

Relevant outcomes to documentSymptoms, functional status (e.g., activities of daily living, NIHSS), quality of life, and imaging changes — use validated measures and adequate follow‑up

Follow‑up importanceLonger follow‑up (months to ≥1 year) often required to assess meaningful clinical benefit

inv-141: Glasgow Coma Scale (GCS) — definition and use in TBI context

Glasgow Coma Scale (GCS)Physician‑administered scale assessing level of consciousness in TBI; severe TBI defined as GCS ≤8

UseBaseline and follow‑up GCS should be documented when assessing HBOT for TBI

inv-142: Glasgow Outcome Scale (GOS) — definition and use in TBI outcomes

Glasgow Outcome Scale (GOS)Physician‑administered categorical scale (1=death to 5=good recovery) used for TBI outcomes; unfavorable outcome often defined as 1–3

UseDocument GOS at longitudinal follow‑up to assess functional outcome after HBOT in TBI trials

inv-143: Rivermead Post-Concussion Symptoms Questionnaire (RPQ) — definition and MCID reference

Rivermead Post‑Concussion Symptoms Questionnaire (RPQ)16‑item measure of somatic, cognitive, and emotional symptoms after mTBI; score range 0–84; MCID ~10% improvement

UseUse RPQ for baseline and follow‑up symptom assessment in HBOT TBI studies

inv-144: PTSD Checklist (PCL) — definition and response thresholds

PTSD Checklist (PCL)17‑item self‑administered measure for PTSD symptoms (score 17–85); treatment response ≥5 points; clinically meaningful change ≥10 points

UseUse PCL to assess PTSD symptom change in HBOT trials involving TBI or comorbid PTSD

inv-145: Systemic HBOT — short descriptor

Short descriptor — systemic HBOTWhole‑body delivery of 100% oxygen at pressures >1.4 ATA in a hard‑sided chamber (monoplace or multiplace)

Coding noteSystemic HBOT is reported with procedure codes such as G0277 (per 30‑minute interval) and provider attendance 99183

inv-146: Comparators — definition of standard/conservative therapies

Comparators — definitionStandard or conservative therapies relevant to the indication (eg, medications, surgery, rehabilitation) used as primary comparators in trials

ImplicationPrior authorization and documentation should show standard therapies were considered or tried before HBOT where appropriate

inv-147: HBOT — short definitional note and trial examples

HBOT definition (short)Hyperbaric oxygen therapy: breathing 100% oxygen at >1 ATA in a pressurized chamber; trials often use 1.5–3.0 ATA

Trial examplesTrials vary by indication in ATA and session length (see specific regimen blocks)

inv-148: HBAT / hyperbaric air — sham/comparator description

HBAT / hyperbaric air (sham)Pressurized room air or slightly pressurized air used as a sham comparator to simulate HBOT conditions in blinded trials

Trial contextUsed in CP and other pediatric trials as the control condition to blind participants and assess placebo effect

inv-149: HBOT regimen examples — trial examples

Vascular dementia example regimen1 hour/day for 24 days with 6 days rest (trial regimen used in vascular dementia RCT)

Femoral head necrosis example regimen30 sessions over 6 weeks at 100% oxygen and 2.5 ATA (Camporesi et al.)

inv-150: Systemic HBOT — concise therapy definition

Systemic HBOT conciseWhole‑body exposure to increased atmospheric pressure with 100% oxygen administered in a chamber to raise tissue oxygen delivery

Indications contextUHMS and ACHM position statements enumerate accepted indications and dosing examples

inv-151: Immediate post-treatment outcome — example immediate effects

Immediate post‑treatment exampleMigraine relief reported within ~45 minutes in pooled trials (immediate symptomatic effect)

ImplicationImmediate effects may not reflect longer‑term clinical benefit; document both short‑ and long‑term outcomes

inv-152: HBOT treatment protocol examples — Efrati and Yildiz protocols

Efrati et al. protocol100% oxygen at 2.0 ATA, 90‑minute sessions, 40 sessions (used in fibromyalgia and neurologic trials)

Yildiz et al. protocol100% oxygen at 2.4 ATA, 90‑minute sessions, 15 sessions (fibromyalgia trial example)

inv-153: EDSS — definition and use in MS trials

EDSS — definitionExpanded Disability Status Scale used to assess disability in multiple sclerosis trials; primary outcome in pooled MS analyses

UseReport EDSS change at prespecified follow‑up intervals (eg, 4 weeks, 6 months)

inv-154: Systemic HBOT — therapeutic rationale

Therapeutic rationale — systemic HBOTIntended to increase oxygen delivery to tissues and potentially sensitize tumors or aid healing by improving local and systemic oxygenation

Clinical implicationRationale underpins use in problem wounds, radiation injury, and selected ischemic conditions

inv-155: Topical Hyperbaric Oxygen Therapy (THOT) — local application rationale

Topical HBOT rationaleDelivers high local oxygen tension to wounds to promote healing by diffusion into tissues; hypothesized benefit for chronic ulcers and refractory wounds

Evidence noteRandomized topical oxygen trials show heterogeneous regimens and populations; UHMS currently does not recommend routine THOT outside research

inv-156: Topical Hyperbaric Oxygen Therapy (THOT) — RCT dosing variation examples

THOT dosing variation in RCTsExamples range from 20 minutes three times daily (short regimen) to 180 minutes twice daily for 12 weeks in refractory venous ulcer trials

ImplicationDosing and duration vary widely across topical HBOT studies, limiting comparability

inv-157: Systemic Hyperbaric Oxygen Therapy (HBOT) — whole‑body exposure and UHMS context

UHMS/ACHM contextUHMS and ACHM position statements list accepted clinical indications and provide dosing examples; UHMS 15th ed (2023) referenced

Use in guidanceUHMS guidance used to inform suggested pressures, session counts, and reevaluation intervals for many indications

inv-158: UHMS indications/manual — cited authority

UHMS as authoritative sourceUndersea & Hyperbaric Medical Society indications/manual cited as an authoritative resource for accepted HBOT indications

Guideline examplesUHMS provides specific recommendations (eg, diabetic foot ulcer guidance) referenced in policy

inv-159: Cochrane reviews — systematic reviews cited

Cochrane/systematic reviews citedMultiple Cochrane and systematic reviews are referenced across indications (eg, stroke, ACS, migraine, MS) to evaluate HBOT effectiveness

ImplicationPolicy conclusions draw on these systematic reviews to determine evidence sufficiency for coverage decisions

inv-160: 99183 — physician attendance/supervision definition

99183Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen chamber, per session

inv-161: G0277 — HBOT full body chamber per 30‑minute interval

G0277Hyperbaric oxygen under pressure, full‑body chamber, reported per 30‑minute interval

inv-162: A4575 — topical hyperbaric oxygen chamber, disposable

A4575Disposable topical hyperbaric oxygen chamber (topical HBOT appliance)

Annual review and policy revision completed.

2023-03annual_review

Annual review and policy revision completed.

2022-03annual_review

Annual review and policy revision completed.

2021-03annual_review

Annual review and policy renewal completed.

2020-03annual_review

Annual review and policy revision completed.

2019-03annual_review

Annual review and policy revision completed.

2018-03annual_review

Annual review and policy revision completed.

2017-03annual_review

Annual review and policy revision completed.

2016-03annual_review

Annual review and policy revision completed.

2015-04annual_review

Annual review and policy revision completed.

2014-05annual_review

Annual review and policy revision completed.

2013-07annual_review

Annual review and policy revision completed.

2012-08annual_review

Annual review and policy revision completed.

2011-08annual_review

Annual review and policy revision completed.