CurrentEmblemHealthPolicy N/A

Topical Oxygen Wound Therapy (TOWT) — Medicaid/Family Health Plus Coverage Criteria

Defines medical necessity, coverage criteria, documentation, prior authorization and coding for topical oxygen wound therapy for EmblemHealth Medicaid/Family Health Plus members.

Policy Summary

PayerEmblemHealth

PolicyTopical Oxygen Wound Therapy (TOWT) — Medicaid/Family Health Plus Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateSep 12, 2025

Key ActionObtain initial electronic prior authorization for A4575 (maximum 16 days per 28-day period) before providing home topical oxygen wound therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Stage IVpressure ulcer stage explicitly covered

16 days/28dinitial A4575 authorization

E1390, A4575procedure codes listed

Numerous ICD-10diagnoses enumerated

NY Medicaidstate guideline cited

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Coverage Criteria for Topical Oxygen Wound Therapy (TOWT)

Eligibility / Covered Indications

Medicaid/Family Health Plus members are eligible when Criterion 1 AND any of Criteria 2-6 are met:

Overall requirement

Allowable wound types and conditions (one or more required)
- 1) Stage IV pressure ulcers: Stage IV pressure ulcer (full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures).
  Require the general program elements above
- 2) Neuropathic (eg, diabetic) ulcers: Neuropathic (for example, diabetic) ulcer with documented participation in a comprehensive diabetic management program and reduction of pressure on a foot ulcer accomplished with appropriate offloading modalities.
  Require the general program elements above
- 3) Venous insufficiency ulcers: Venous insufficiency ulcer with consistent application of compression bandages and/or garments and documentation that leg elevation and ambulation have been encouraged.
  Require the general program elements above
- 4) Non-healing surgically created or traumatic wounds: Non-healing surgically created or traumatic wound where documentation supports medical necessity for accelerated granulation that cannot be achieved by other topical wound treatments.
  Require the general program elements above
- 5) Chronic ulcer of mixed etiology: Chronic ulcer present for at least 30 days of mixed etiology.>= 30 days
  Require the general program elements above

TOWT is investigational and not medically necessary for indications other than those explicitly specified in this policy. The policy lists specific exclusions and states that topical oxygen wound therapy is considered investigational, medically contraindicated and not covered for all other indications not meeting the eligibility criteria.

When billing and documenting TOWT for covered indications, providers must use an applicable ICD-10 diagnosis code from the enumerated lists for non-pressure chronic ulcers (L97 series) and chronic ulcers of other sites (L98 series). The policy provides extensive L97 and L98 code listings to identify eligible chronic ulcers of the lower leg, ankle, foot, heel, buttock, back, and other skin sites.

Use of topical oxygen wound therapy for indications outside the covered criteria — including Stage I, II or III pressure ulcers — is specifically identified as not medically necessary or investigational and therefore not covered under this policy.

Prior authorization and other procedural requirements for topical oxygen wound therapy in this policy reference the New York State Medicaid Topical Oxygen Wound Therapy Guidelines (March 2008). Providers should follow the referenced state guidance when preparing prior authorization requests and clinical documentation.

Coding and Authorization Units

Applicable Procedure CodesHCPCSCovered

A4575	Topical hyperbaric oxygen chamber, disposable.
E1390	Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate

Applicable ICD-10 Diagnosis Codes (selected examples from long list)ICD-10

E08.621	Diabetes mellitus due to underlying condition with foot ulcer
E08.622	Diabetes mellitus due to underlying condition with other skin ulcer
E08.628	Diabetes mellitus due to underlying condition with other skin complications
E09.621	Drug or chemical induced diabetes mellitus with foot ulcer
E09.622	Drug or chemical induced diabetes mellitus with other skin ulcer
E09.628	Drug or chemical induced diabetes mellitus with other skin complications
E10.621	Type 1 diabetes mellitus with foot ulcer
E10.622	Type 1 diabetes mellitus with other skin ulcer
E11.621	Type 2 diabetes mellitus with foot ulcer
E11.622	Type 2 diabetes mellitus with other skin ulcer

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Applicable ICD-10 Diagnosis CodesICD-10Covered

L97.303	Non-pressure chronic ulcer of unspecified ankle with necrosis of muscle.
L97.304	Non-pressure chronic ulcer of unspecified ankle with necrosis of bone.
L97.305	Non-pressure chronic ulcer of unspecified ankle with muscle involvement without evidence of necrosis.
L97.306	Non-pressure chronic ulcer of unspecified ankle with bone involvement without evidence of necrosis.
L97.308	Non-pressure chronic ulcer of unspecified ankle with other specified severity.
L97.309	Non-pressure chronic ulcer of unspecified ankle with unspecified severity.
L97.311	Non-pressure chronic ulcer of right ankle limited to breakdown of skin.
L97.312	Non-pressure chronic ulcer of right ankle with fat layer exposed.
L97.313	Non-pressure chronic ulcer of right ankle with necrosis of muscle.
L97.314	Non-pressure chronic ulcer of right ankle with necrosis of bone.

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Initial A4575 auth units — A4575 (topical hyperbaric oxygen chamber, disposable)

Initial authorization limitMaximum 16 days in a 28‑day period (treatment pattern: 4 days on, 3 days off).

How to requestProvider should request authorization once for the number of days (units) based on the written order.

Prior approval for extended treatmentPrior approval is required for treatment exceeding 4 weeks (extensions require documentation).

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

An initial prior authorization is required when topical oxygen wound therapy (TOWT) has not been attempted in a facility prior to home use. If TOWT was not previously attempted in a hospital or other health care facility, providers must request an initial electronic prior authorization for two weeks (8 days/units). Prior approval is required for treatment exceeding the initial period or exceeding 4 weeks. E1390 is not prior authorized and is billed monthly.

Initial electronic prior authorization (DVS) for A4575: maximum 16 days per 28-day period when continuing therapy (treatment pattern: 4 days on, 3 days off).
If TOWT has not been attempted in a facility prior to home use: initial prior authorization = 2 weeks (8 days/units).
Prior approval required for treatment beyond initial approved period and for treatments exceeding 4 weeks.
E1390 (oxygen concentrator) is not prior authorized; bill monthly.

Note

Facility-first Attempt Recommended

Providers must attempt TOWT first in an inpatient or other health care facility prior to discharge to the home setting when clinically appropriate. Documentation should show the facility attempt, patient tolerance/compliance and pain management during application of TOWT; if no facility attempt occurred, document rationale and obtain the initial prior authorization described above.

Facility-first attempt expected prior to home use.
If no facility attempt, obtain initial 2-week prior authorization and document reason.

Denial Risk

Reference-driven Denial Risk

Failure to submit the clinical evidence required by the Plan or to meet referenced New York State Medicaid TOWT criteria may result in denial of the request. Prior approval beyond the initial period will not be granted if documentation is insufficient or if measurable wound healing has not occurred or deterioration is documented.

Reference: New York State Medicaid Topical Oxygen Wound Therapy Guidelines (see References).
Insufficient documentation or lack of measurable healing/deterioration risks denial.
Ensure all required clinical evidence is submitted with prior authorization requests.

Billing Rule

Required Diagnosis Coding

Use applicable ICD-10 diagnosis codes from the L97/L98 series describing non-pressure chronic ulcers or chronic ulcer of skin as the primary diagnosis for TOWT claims and authorizations. Select the most specific code reflecting laterality and ulcer severity/depth.

Examples include L97.xxx series codes for non-pressure chronic ulcers (select code specifying location, laterality and severity).
Choose the most specific ICD-10 code to reflect wound characteristics (length, depth, necrosis, etc.).

Documentation Required

Required Medical Record Documentation

Maintain complete wound therapy documentation in the medical record to support prior authorization and continuation of TOWT. Required documentation includes dressing types and frequency of change, precise wound measurements (length, width, depth/surface area), quantity of exudate, presence of granulation or necrotic tissue, concurrent wound care measures (debridement, nutrition, support surfaces, positioning, incontinence control), patient/family training and compliance, and the original signed written order from a qualified licensed prescriber.

Dressing types/frequency, weekly quantitative wound measurements, exudate amount, granulation/necrosis.
Documentation of prior treatment regimens and how patient meets coverage criteria.
Evidence of patient compliance and training in dressing application and oxygen hookup.
Original signed written order specific to the item requested is required.

Definitions and Key Terms

Topical oxygen wound therapy (TOWT)

DefinitionControlled application of 100% oxygen directly to an open moist wound at slightly higher than atmospheric pressure using an oxygen concentrator connected to FDA‑approved disposable O2 boot and/or O2 sacral device.

Delivery methodOxygen concentrator connected to disposable topical oxygen devices (O2 boot/sacral device).

PurposeMaintain a sealed, oxygen‑rich environment at the wound to promote granulation and healing when other standard wound therapies have been attempted.

Pressure ulcer staging — Stages I–IV

Stage INonblanchable erythema of intact skin (light skin) or darker/violet hue in darkly pigmented skin.

Stage IIPartial‑thickness skin loss involving epidermis and/or dermis.

Stage IIIFull‑thickness skin loss with damage or necrosis of subcutaneous tissue; may extend to but not through underlying fascia.

Stage IVFull‑thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

Wound healing — improvement versus lack of improvement

Improvement (healing) definitionReduction in wound surface area or reduction in wound depth (quantitative measurements).

Lack of improvementNo measurable progress in surface area or depth over the documented observation period.

Documentation requirementWeekly quantitative wound measurements should be submitted when requesting extensions.

Non‑pressure chronic ulcer (L97) — ICD‑10 codes

DescriptionICD‑10 codes for non‑pressure chronic ulcers of the lower leg, ankle, foot and heel (L97 series) with varying severity including skin breakdown, fat layer exposed, muscle or bone involvement, and necrosis.

Example codesL97.303, L97.304, L97.305, L97.306, L97.308, L97.309, L97.311, L97.312, L97.313, L97.314

Use on claimsAn applicable L97 diagnosis code must be documented on claims and clinical records to support coverage criteria.

Chronic ulcer of other sites (L98) — ICD‑10 codes

DescriptionICD‑10 codes for chronic ulcers of other sites (L98 series) including buttock, back and other skin sites with severity descriptors (skin breakdown, fat layer exposed, muscle or bone involvement, necrosis).

Example codesL98.412, L98.413, L98.414, L98.415, L98.416, L98.418, L98.419, L98.421, L98.422, L98.423

Use on claimsAn applicable L98 diagnosis code must be documented on claims and clinical records to support coverage criteria.

OpenPayer

Topical Oxygen Wound Therapy (TOWT) — Medicaid/Family Health Plus Coverage Criteria

Coverage Criteria for Topical Oxygen Wound Therapy (TOWT)

Coding and Authorization Units

Provider Requirements, Prior Authorization, and Documentation

Background on Topical Oxygen Wound Therapy

Definitions and Key Terms