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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyDHA HBO Therapy Coverage Policy Update | OpenPayer
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    ModifiedDHAPolicy 6010.60-M

    Hyperbaric Oxygen (HBO) Therapy

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    This document identifies the DHA policy section governing Hyperbaric Oxygen (HBO) Therapy under Medicine services. The substantive coverage criteria, authorization requirements, documentation requirements, and coding details are not present in this document window.

    Policy Summary
    PayerDHA
    PolicyHyperbaric Oxygen (HBO) Therapy
    Policy CodePolicy 6010.60-M
    Change TypeCoverage expansion
    Effective DateJul 27, 2006
    Next Review DateNot scheduled
    Key ActionProvide HBO therapy only in an approved institutional facility or a freestanding facility approved as a Corporate Services Provider.
    SourceLink
    POLICY UPDATE CHANGES

    Coverage was expanded to allow HBO therapy furnished by a freestanding HBO therapy facility when the facility is properly approved as a Corporate Services Provider.

    The policy was revised in Revision 133 on September 19, 2024 to add the freestanding-facility coverage and effective-date provisions.

    4Primary HBO indications
    6Adjunctive HBO indications
    5Excluded uses
    2Eligible facility categories
    99183Covered CPT code

    Covered and Unproven Indications

    Primary HBO indications

    HBO therapy may be covered when provided by an eligible facility and one of the following indications is present.

    Coverage requirements

    • Eligible facility

      • Facility type

        • The service is provided by an approved institutional provider, such as a hospital.
        • The service is provided by a freestanding HBO therapy facility properly approved as a Corporate Services Provider (CSP).

    • Indication

      • Decompression sickness.
    Policy Summary
    PayerDHA
    PolicyHyperbaric Oxygen (HBO) Therapy
    Policy CodePolicy 6010.60-M
    Change TypeCoverage expansion
    Effective DateJul 27, 2006
    Next Review DateNot scheduled
    Key ActionProvide HBO therapy only in an approved institutional facility or a freestanding facility approved as a Corporate Services Provider.
    SourceLink
    On This Page
    Covered and Unproven IndicationsCovered Procedure CodeProvider and Facility RequirementsHyperbaric Oxygen Therapy OverviewKey Terms

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

  1. Carbon monoxide poisoning.
  2. Air or gas embolism.
  3. Profound blood loss when blood transfusion cannot be accomplished.

    4. Adjunctive HBO indications

    HBO therapy may be covered as an adjunct to standard therapy when an eligible facility provides the service and one of the following indications is present.

    Coverage requirements

    • Eligible facility

      • The service is provided by an approved institutional provider, such as a hospital.
      • The service is provided by a freestanding HBO therapy facility properly approved as a Corporate Services Provider (CSP).

    • Adjunctive treatment

      • HBO therapy is used as an adjunct to standard therapy.

      • Indication

        • Acute soft tissue injury, including crush injury, compartment syndrome, acute traumatic peripheral ischemia, or blast injury.
        • Clostridial myositis and myonecrosis.
        • Compromised skin grafts and/or flaps.
        • Chronic, severe, and/or gangrenous diabetic foot wounds.
        • Ostoradionecrosis.
        • Osteomyelitis refractory to standard medical management.

    Other indications

    Other indications may be covered only when proven.

    Other proven indication

    • The indication is supported by reliable evidence demonstrating that HBO therapy is safe, effective, and comparable or superior to standard care.Reliable evidence demonstrating safety, effectiveness, and outcomes comparable or superior to standard care

    HBO therapy is unproven for traumatic brain injury, stroke, cerebral palsy, and autism. It is also unproven when used as adjunctive treatment for thermal burns.

    Covered Procedure Code

    Covered CPT CodesCPTCovered
    99183Hyperbaric oxygen therapy

    Provider and Facility Requirements

    Billing Rule

    Use an Approved Facility

    Provide HBO therapy only through an approved institutional provider, such as a hospital, or through a freestanding HBO therapy facility properly approved as a Corporate Services Provider (CSP).

    Documentation Required

    Document Other Indications

    For indications not specifically listed in this policy, submit documentation showing that HBO therapy is supported by reliable evidence and is proven for the requested use.

    Denial Risk

    Avoid Unproven Indications

    HBO therapy is unproven and may be denied when requested for traumatic brain injury, stroke, cerebral palsy, autism, or as adjunctive treatment for thermal burns.

    • Traumatic brain injury (TBI)
    • Stroke
    • Cerebral palsy
    • Autism
    • Thermal burns
    Documentation Required

    Support Other Indications With Evidence

    When requesting HBO therapy for an indication not listed in the policy, support the request with reliable evidence demonstrating that the treatment is safe, effective, and comparable or superior to standard care.

    • Evidence must address safety and efficacy.
    • Evidence must demonstrate comparable or superior outcomes to standard care.

    Hyperbaric Oxygen Therapy Overview

    Hyperbaric oxygen (HBO) therapy places the patient entirely within a pressure chamber while the patient breathes oxygen at a pressure greater than one atmosphere.

    Key Terms

    Hyperbaric oxygen (HBO) therapy
    Treatment modalityA mode of medical treatment in which the patient is entirely enclosed in a pressure chamber breathing oxygen at a pressure greater than one atmosphere.
    Corporate Services Provider (CSP)
    Provider facility categoryA freestanding HBO therapy facility properly approved as a Corporate Services Provider (CSP) under the applicable TRICARE requirements.