ModifiedExcellus Health Plan IncPolicy 2.01.07

Hyperbaric Oxygen Therapy (HBOT)

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This policy governs coverage determinations for topical and systemic hyperbaric oxygen therapy, identifying topical therapy as investigational and describing medically appropriate systemic indications, including criteria for selected diabetic lower-extremity wounds.

Policy Summary

PayerExcellus Health Plan Inc

PolicyHyperbaric Oxygen Therapy (HBOT)

Policy CodePolicy 2.01.07

Change TypeModified

Effective DateJuly 16, 2026

Next Review DateJuly 1, 2027

Key ActionProvide HBOT with continuing standard wound care and do not use it as a replacement for successful standard therapeutic measures.

SourceLink

POLICY UPDATE CHANGES

Idiopathic sudden sensorineural hearing loss and central retinal artery occlusion were added to medically necessary indications and removed from investigational indications.

The policy was reviewed annually with policy intent unchanged.

InvestigationalTopical therapy status

Wagner 3+Diabetic wound severity

30 daysStandard wound therapy before HBOT

6Systemic indication categories

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ModifiedExcellus Health Plan IncPolicy 2.01.07

Hyperbaric Oxygen Therapy (HBOT)

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Policy Summary

PayerExcellus Health Plan Inc

PolicyHyperbaric Oxygen Therapy (HBOT)

Policy CodePolicy 2.01.07

Change TypeModified

Effective DateJuly 16, 2026

Next Review DateJuly 1, 2027

Key ActionProvide HBOT with continuing standard wound care and do not use it as a replacement for successful standard therapeutic measures.

SourceLink

POLICY UPDATE CHANGES

Idiopathic sudden sensorineural hearing loss and central retinal artery occlusion were added to medically necessary indications and removed from investigational indications.

The policy was reviewed annually with policy intent unchanged.

InvestigationalTopical therapy status

Wagner 3+Diabetic wound severity

30 daysStandard wound therapy before HBOT

6Systemic indication categories

14Listed HBOT indications

Coverage Criteria

Systemic HBOT: Medically Appropriate Indications

Systemic HBOT in a pressurized chamber is medically appropriate for the following indications, subject to condition-specific recommendations.

Medically appropriate indications

Acute traumatic peripheral ischemia or insufficiency, including crush injury, compartment syndrome, reperfusion injury, and suturing of severed limbs.
Acute air or gas embolism.
Acute carbon monoxide poisoning.
Central retinal artery occlusion.
Acute cerebral edema.

Selected Diabetic Lower-Extremity Wounds

HBOT is medically appropriate for enhancement of healing in selected nonhealing diabetic lower-extremity wounds when ALL criteria are met.

ALL required criteria

The wound is a lower-extremity wound due to diabetes.
The wound is classified as Wagner grade 3 or higher.
Grade 3 includes abscess, osteomyelitis, pyarthrosis, plantar-space abscess, or infection of tendons or tendon sheaths; grade 4 includes forefoot gangrene.
There are no measurable signs of healing after 30 days of an adequate course of standard wound therapy.>= 30 days
Standard wound therapy includes applicable measures
- Assessment of vascular status and correction of vascular problems in the affected limb, if possible.

Listed HBOT Indications

The following indications are listed as medically appropriate systemic HBOT indications.

ANY of the following

Central retinal artery occlusion.
Chronic refractory osteomyelitis, persisting at least six weeks or recurring after surgical debridement and at least one appropriate course of parenteral antibiotics.
Refractory mycosis, including mucormycosis, actinomycosis, or Conidiobolus coronatus.

Investigational Indications

Systemic HBOT is considered investigational for all other indications, including but not limited to the following.

ANY of the following

Acute ischemic stroke.
Bell's palsy.
Bone grafts.

Investigational Indications: Expanded List

Systemic HBOT is investigational for the following additional indications.

ANY of the following

Breast cancer, locally advanced, as pretreatment for chemotherapy.
Brown recluse spider bites.
Acute carbon tetrachloride poisoning.
Cardiopulmonary bypass as pretreatment.
Cerebral palsy.
Acute or chronic cerebrovascular disease, thrombotic or embolic.

Nonhealing Diabetic Lower-Extremity Wounds

Utilization recommendations for nonhealing diabetic lower-extremity wounds include the following.

ALL of the following

Wagner grade 3 or higher diabetic lower-extremity wound.
Failure of standard wound therapy for at least 30 consecutive days.>= 30 days
Treatment at 2.0–3.0 ATA for approximately 90 minutes, five days per week, with continuing standard wound care.

Continuation Therapy

Continuation of HBOT for diabetic lower-extremity wounds requires documented progress.

ALL of the following

Weekly wound measurements document progress, including precise wound length, width, and depth; granulation and necrotic tissue; and concurrent wound therapy.
A steady decrease in wound volume is demonstrated from week to week.
The patient has not healed, become unable to tolerate treatment, or failed to improve.
Measurable signs of healing have been demonstrated within each 30-day treatment period.within 30 days

Medical Necessity Documentation

Medical records must support the specific condition treated and the medical necessity of HBOT.

ALL of the following

Initial assessment, medical history, and physical examination, including prior treatments such as antibiotic therapy and surgical interventions.
Current adjunctive treatment, including its type and effectiveness.
Established HBOT goals.
HBOT session records documenting physical findings and treatment rendered, including ascent and descent time, total compression time, oxygen dose, pressurization level, attendance, and events.
Effect of treatment on established HBOT goals.

Condition-Specific Utilization Recommendations

Condition-specific pressure, patient-selection, treatment-duration, and utilization-review recommendations apply as described below.

ANY of the following

Air or gas embolism: gases in the vasculature interfere with organ function or cause ischemia; typically one to two treatments, occasionally five to ten; review after 10 treatments.
Severe anemia: use when transfusion is impossible or must be delayed; treatment may be three to four hours, three to four times daily, with tapering as appropriate.
Nonhealing diabetic lower-extremity wound: Wagner grade 3 or higher and failure of standard therapy for at least 30 days; review after 40 treatments.
Carbon monoxide poisoning: initiate within six hours of removal from the contaminated environment; additional treatments may be given for persistent neurologic dysfunction; review after five treatments.

Acute Carbon Monoxide Poisoning

HBOT may be used for acute carbon monoxide poisoning according to the following utilization recommendations.

ALL of the following

The patient has been removed from the carbon monoxide-contaminated environment.within 6 hours
Initial treatment is provided; if neurologic dysfunction persists, further treatment may occur within six to eight hours and once or twice daily until no additional cognitive improvement is seen.

Occlusion and Vascular Compromise

For occlusion or vascular compromise, HBOT is adjunctive and must be considered with the clinical circumstances and standard therapeutic measures.

Occlusion or vascular compromise

ALL of the following
- The length of time of the occlusion is documented.
- The anatomical site of the occlusion is documented.
- The presence or absence of a patent cilioretinal artery is documented when evaluating central retinal artery occlusion.
- The diagnosis of central retinal artery occlusion is established, typically by fundoscopic examination.
Threatened tissue or vascular compromise

Crush Injury

HBOT for crush injury is used with standard therapeutic measures when tissue or function is threatened.

ALL of the following

Crush injury is present.
Loss of function, limb, or life is threatened.
Tissue oxygen tension is below 30 mmHg.< 30 mmHg
HBOT is provided in conjunction with standard therapeutic measures.

Acute Cyanide Poisoning

HBOT may be used as an adjunct to sodium nitrite or other appropriate cyanide therapy.

ALL of the following

Acute cyanide poisoning is present.
HBOT is adjunctive to infusion of sodium nitrite.
One treatment of approximately 120 minutes is provided.

Acute Decompression Sickness

HBOT is recommended for decompression sickness when gas bubbles impair organ function or alter sensation.

ALL of the following

Gas bubbles are present in tissue or blood in volumes sufficient to interfere with organ function or cause altered sensation.
Treatment is provided at 2.0–5.0 ATA.
One treatment of 1.5–14 hours is provided, with additional treatments for residual defects until clinical stability; generally no more than 5–10 treatments.

Clostridial Gas Gangrene

HBOT is adjunctive treatment for clostridial gas gangrene.

ALL of the following

Findings support gas gangrene, such as a positive gram-stained smear or culture, tissue gas on imaging, severe sudden pain, skin changes, or systemic deterioration.
Treatment is provided with appropriate standard therapy: three 90-minute treatments during the first 24 hours, followed by two treatments daily for two to five days.

Idiopathic Sudden Sensorineural Hearing Loss

HBOT may be used for idiopathic sudden sensorineural hearing loss as specified below.

ALL of the following

Hearing loss is typically at least 30 decibels across three contiguous audiogram frequencies.>= 30 dB across 3 contiguous frequencies
ANY of the following
- HBOT is combined with steroid therapy near onset.
- HBOT is combined with steroid therapy as salvage within one month of onset.within 1 month
Recommend approximately 10–20 sessions; utilization review after 20 treatments.

Necrotizing Soft-Tissue Infection

HBOT is adjunctive therapy only for necrotizing soft-tissue infection.

ALL of the following

Morbidity and mortality are expected to be high despite aggressive standard treatment.
HBOT is used only as adjunctive therapy.
Treatment is twice daily for 90–120 minutes until stabilized, then once daily; utilization review after 30 treatments.

Chronic Osteomyelitis

HBOT is not primary treatment for chronic osteomyelitis.

ALL of the following

Chronic refractory osteomyelitis has persisted for at least six weeks or has recurred.
Surgical debridement has been performed.
At least one appropriate six-week course of parenteral antibiotics has been completed.
HBOT is adjunctive to, and not a replacement for, standard treatment.

Osteoradionecrosis

HBOT may be used as adjunctive preoperative and postoperative treatment for osteoradionecrosis.

ALL of the following

Osteoradionecrosis is present.
HBOT is used as adjunctive treatment in the preoperative and postoperative management of the patient.
Treatment and surgical debridement follow the applicable stage-based protocol.

Mandibular Osteoradionecrosis: Marx Protocol

The Marx Protocol applies to mandibular osteoradionecrosis associated with dental surgery.

ALL of the following

Mandibular osteoradionecrosis is present, with evidence of overt fracture or bony resorption.
The patient is undergoing dental surgery or extraction requiring the Marx Protocol.
Pre- and post-treatment HBOT is provided according to disease stage; utilization review occurs after 10–30 treatments.

Refractory Mycosis

HBOT for refractory mycosis is used only with standard treatment.

ALL of the following

Refractory mycosis is present, such as actinomycosis or mucormycosis.
The disease process is refractory to standard treatment and HBOT is provided in conjunction with standard treatment.
Treatment is one to two times daily for 90–120 minutes and may continue up to 40–80 treatments.

Diabetic Foot Ulcer Guideline Criteria

Guidelines support adjunctive HBOT for selected diabetic foot ulcers that fail to improve with standard wound therapy.

ALL of the following

The diabetic foot ulcer is Wagner grade 3 or higher.
The ulcer has not shown significant improvement after at least 30 days of standard-of-care therapy.>= 30 days
Alternatively, after at least four weeks of standard wound therapy, wound area reduction is less than 50%.< 50% area reduction
Adequate perfusion is present when applying the guideline option for ulcers failing four to six weeks of conservative management.

Sudden Sensorineural Hearing Loss Guideline Options

Guidelines identify HBOT combined with steroid therapy as an option for selected sudden sensorineural hearing loss.

ANY of the following

HBOT combined with steroid therapy is offered within two weeks of onset.within 2 weeks
HBOT combined with steroid therapy is offered as salvage within one month of onset.within 1 month

UHMS and Vascular-Guideline Indications

UHMS and vascular guidelines identify the following potential indications or adjunctive uses.

ANY of the following

Selected Wagner grade 3 or higher diabetic foot ulcers failing standard therapy for 30 days.
Acute postoperative HBOT added to standard care after foot surgery for a Wagner grade 3 or higher diabetic ulcer.
HBOT as adjunctive therapy to revascularization for wound healing in chronic limb-threatening ischemia and diabetic foot ulcers.
Central retinal artery occlusion, recognizing that evidence remains uncertain.

Compromised grafts and flaps may be treated with HBOT when clinically appropriate, but HBOT is not covered for primary management of the wound. It is an adjunct to appropriate surgical and wound-care measures.

Hydrogen sulfide poisoning, inflammatory bowel disease including Crohn's disease and ulcerative colitis, and interstitial cystitis are considered investigational and are not covered under this policy.

Intra-abdominal or intracranial abscesses, in vitro fertilization, and lepromatous leprosy are considered investigational and are not covered under this policy.

Malignant otitis externa, meningitis, and migraine are considered investigational and are not covered under this policy.

Myocardial infarction or acute coronary syndrome, multiple sclerosis, and delayed-onset muscle soreness are considered investigational and are not covered under this policy.

Prevention of coronary restenosis, pseudomembranous colitis, and pyoderma gangrenosum are considered investigational and are not covered under this policy.

Radiation myelitis, radiation therapy for tumor sensitization, and retinal detachment are considered investigational and are not covered under this policy.

Adjunctive HBOT for sickle cell peripheral retinopathy with scleral buckling is considered investigational and is not covered under this policy.

Continued treatment for diabetic lower-extremity wounds is not covered when measurable signs of healing have not been demonstrated within any 30-day treatment period. Most patients should not require more than 40 treatments; patients who do not respond to 40 treatments are unlikely to respond to 60, 80, or 120 treatments.

HBOT is not a primary treatment for chronic osteomyelitis. It should be considered only after surgical debridement and at least one appropriate six-week course of parenteral antibiotics.

HBOT for acute ischemic stroke unrelated to cerebral air embolism should be offered only in the context of a clinical trial or for individuals with cerebral air embolism.

The FDA has not cleared or authorized HBOT for COVID-19 or conditions beyond those listed in its cleared indications. Safety and effectiveness have not been established for numerous other conditions, including AIDS/HIV, Alzheimer's disease, asthma, Bell's palsy, brain injury, cerebral palsy, depression, heart disease, hepatitis, migraine, multiple sclerosis, Parkinson's disease, spinal cord injury, sports injury, and stroke.

Codes may not be covered under all circumstances. Coverage is subject to the member's product, benefit terms, applicable governmental guidance, and the policy criteria. Medical policy criteria do not override a product exclusion or noncovered benefit.

HBOT should not replace successful standard therapeutic measures. The medical record must support the specific condition being treated and the medical necessity of HBOT; continuation is not covered without measurable healing progress when required by the applicable criteria.

Evidence does not support HBOT for autism spectrum disorder. A randomized controlled trial found no significant improvement over sham treatment, and UHMS does not recommend routine treatment of autism with HBOT. Potential adverse effects include ear barotrauma.

Coding and Clinical Thresholds

Policy designationsmixed

(E/I)	Experimental/Investigational
(NMN)	Not medically necessary/appropriate

CPT CodesCPT

99183

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

HCPCS Codes — Experimental/InvestigationalHCPCSExperimental

A4575	Topical hyperbaric oxygen chamber, disposable (E/I)
E0446	Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories (E/I)

HCPCS CodesHCPCS

G0277

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

ICD10 CodesICD-10

A18.01	Tuberculosis of spine
A18.03	Tuberculosis of other bones
A42.0-A42.2	Actinomycosis (code range)
A42.81-A42.89	Other forms of actinomycosis (code range)
A42.9	Actinomycosis, unspecified
A43.0-A43.9	Nocardiosis (code range)
A48.0	Gas gangrene
A50.01-A50.09	Early congenital syphilis, symptomatic (code range)
A52.77	Syphilis of bone and joint
B36.0-B36.9	Other superficial mycoses (code range)

1–10 of 22

1/3

ICD10 CodesICD-10

E13.52-	Other specified diabetes mellitus (code range)
G93.6	Cerebral edema
H05.021-H05.029	Osteomyelitis of orbit (code range)
H90.3	Sensorineural hearing loss, bilateral
H90.5	Unspecified sensorineural hearing loss
H90.A2-H90.A22	Sensorineural hearing loss, unilateral, with restricted hearing on the contralateral side (code range)
H91.2-H91.23	Sudden idiopathic hearing loss (code range)
H34.1-H34.13	Central retinal artery occlusion (code range)
I70.361-	Atherosclerosis of bypass graft(s) of the extremities with gangrene (code range)
I70.461-	Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene (code range)

1–10 of 19

1/2

ICD10 CodesICD-10

L98.3	Eosinophilic cellulitis (Wells)
M27.2	Inflammatory conditions of jaws
M27.8	Other specified diseases of jaws
M46.20-M46.28	Osteomyelitis of vertebra (code range)
M46.30-M46.39	Infection of intervertebral disc (pyogenic) (code range)
M86.00-M86.09	Acute hematogenous osteomyelitis (code range)
M86.10-M86.19	Other acute osteomyelitis (code range)
M86.20-M86.29	Subacute osteomyelitis (code range)
M86.30-M86.69	Chronic osteomyelitis (code range)
M86.8x0-M86.9	Other and unspecified osteomyelitis (code range)

1–10 of 19

1/2

ICD10 CodesICD-10

T70.3xxA-T70.3xxS	Caisson disease (decompression sickness) (code range)
T79.0xxA-T79.0xxS	Air embolism (traumatic) (code range)
T86.820-T86.822	Complications of skin graft (allograft) (autograft) (code range)
T86.828-T86.829	Other and unspecified complications of skin graft (allograft) (autograft)

Wagner wound classification threshold

Minimum Wagner gradeGrade 3 or higher

Grade 2Ulcer penetrates to tendon, bone or joint

Grade 3Lesion penetrates deeper than Grade 2 and includes abscess, osteomyelitis, pyarthrosis, plantar space abscess, or infection of the tendon and tendon sheaths

Grade 4Gangrene of the forefoot

Standard wound therapy duration before HBOT consideration

Provider Actions and Denial Risks

Step Therapy

Continue Concurrent Standard Wound Therapy

Continue appropriate standard wound therapy concurrently with HBOT; HBOT must be used as an adjunct and not as a replacement for successful standard therapeutic measures.

Standard wound care may include vascular assessment and correction, nutritional and glucose optimization, debridement, moist wound care, off-loading, and treatment of infection.

Documentation Required

Document Initial Assessment and Treatment Plan

Before initiating HBOT, document the condition requiring treatment, relevant medical history, physical examination, prior treatments, and established HBOT goals.

Include prior antibiotic therapy and surgical interventions.
Document current adjunctive treatment and its effectiveness.
State measurable HBOT goals.

Policy Background

Systemic HBOT places the patient in a pressurized chamber while the patient breathes nearly 100% oxygen intermittently at a pressure greater than one atmosphere. The policy considers systemic HBOT medically appropriate for specified acute conditions and selected nonhealing lower-extremity wounds, including acute traumatic peripheral ischemia or insufficiency, acute air or gas embolism, acute carbon monoxide poisoning, central retinal artery occlusion, acute cerebral edema, and qualifying diabetic wounds. For selected diabetic wounds, HBOT is an adjunct to standard care after an adequate course of wound therapy—including vascular assessment and correction when possible, nutritional and glucose optimization, debridement, appropriate moist dressings, off-loading, and infection treatment—has failed to produce measurable healing. Topical HBOT, which delivers oxygen directly to the wound at slightly greater than atmospheric pressure, is considered investigational.

Definitions and Abbreviations

Wagner wound grade definitions

Grade 2Ulcer penetrates to tendon, bone or joint

Grade 3Lesion penetrates deeper than Grade 2 and includes abscess, osteomyelitis, pyarthrosis, plantar space abscess, or infection of the tendon and tendon sheaths

Grade 4Gangrene of the forefoot

ATA definition and pressure equivalencies

TermAtmospheres absolute

Pressure equivalency1 ATA equals 760 mmHg

Additional equivalencies14.7 psi, 760 torr, or 33 feet of seawater

Revision History

11/19/99Original effective date

Policy originally became effective.

06/26/25Material revisionLatest

Annual review added idiopathic sudden sensorineural hearing loss and central retinal artery occlusion to medically necessary indications and removed them from investigational indications.

Policy Summary

PayerExcellus Health Plan Inc

PolicyHyperbaric Oxygen Therapy (HBOT)

Policy CodePolicy 2.01.07

Change TypeModified

Effective DateJuly 16, 2026

Next Review DateJuly 1, 2027

Key ActionProvide HBOT with continuing standard wound care and do not use it as a replacement for successful standard therapeutic measures.

SourceLink

On This Page

Optimization of nutritional status.

Optimization of glucose control.

Debridement by any means to remove devitalized tissue.

Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings.

Appropriate off-loading.

Treatment to resolve any infection.

Chronic nonhealing wounds, except covered selected diabetic lower-extremity wounds.

Complex regional pain syndrome.

Uncompromised skin grafts or flaps.

Fibromyalgia syndrome.

Traumatic head injury, including traumatic brain injury.

Hydrogen sulfide poisoning.

Inflammatory bowel disease, including Crohn's disease and ulcerative colitis.

Occlusion and vascular compromise: see condition-specific criteria below.

Crush injury: use with standard therapy when loss of function, limb, or life is threatened and tissue oxygen tension is below 30 mmHg.

Loss of function, limb, or life is threatened.

Tissue oxygen tension is below 30 mmHg.< 30 mmHg

HBOT is provided in conjunction with standard therapeutic measures.

Required duration30 days

Healing requirementNo measurable signs of healing after an adequate course of standard wound therapy

Standard therapy may includeVascular assessment and correction, nutritional and glucose optimization, debridement, moist dressings, off-loading, and treatment of infection

Chronic refractory osteomyelitis persistence requirement

Persistence requirementAt least six (6) weeks

Alternative pathwayThe condition has recurred after appropriate interventions

Required prior interventionsSurgical debridement and at least one appropriate course of parenteral antibiotics

No measurable healing threshold for continued treatment

Measurement intervalWithin any 30-day period of treatment

Required findingMeasurable signs of healing must be demonstrated

Continuation statusContinued treatment is not covered when the required healing signs are absent

Typical diabetic lower-extremity wound treatment course

Session duration90 minutes

FrequencyFive days per week

Typical treatment courseMay last for 30-40 treatments

Concurrent carePerformed in conjunction with continuing standard wound care

Diabetic wound patient-selection threshold

Wagner severityGrade 3 or higher

Standard-care failureFailure of standard wound therapy for at least 30 consecutive days

Treatment settingNon-healing diabetic wounds of the lower extremities

Tissue oxygen tension threshold

Tissue oxygen tensionBelow 30 mmHg

Clinical contextThreatened loss of function, limb, or life

UseReferenced for compromised tissue or decreased perfusion

Sudden sensorineural hearing loss audiometric threshold

Audiometric threshold30 decibels or more

Frequency patternAcross 3 contiguous frequencies

Assessment methodAudiogram

Immediately available practitioner response time

Response requirementMaximum five-minute response time to the chamber

On-campus outpatient or provider-based settingPhysician or qualified non-physician practitioner must be present in the office suite or at a location meeting the response-time requirement

Physician-office settingPhysician or qualified non-physician practitioner must be present in the office suite

Diabetic foot ulcer severity threshold

Minimum severityWagner Grade 3 or higher

Lower-severity ulcersThe guideline suggests against HBOT for Wagner Grade 2 or lower diabetic foot ulcers

Qualifying responseNo significant improvement after 30 days of standard-of-care therapy

Standard wound-care duration before HBOT

Standard-care period30 days

Required responseNo significant improvement

Therapy typeStandard-of-care therapy

Diabetic foot ulcer wound-response threshold

Required wound-area response>50% wound area reduction

Minimum standard-therapy durationAt least 4 weeks

Recommended adjunctAdjunctive therapy such as HBOT

Initial SSNHL HBOT timing

Initial timingWithin 2 weeks of onset

Combination therapyHBOT combined with steroid therapy

Recommendation typeClinicians may offer or refer for HBOT

Salvage SSNHL HBOT timing

Salvage timingWithin 1 month of onset

Combination therapyHBOT combined with steroid therapy

Recommendation typeClinicians may offer or refer for salvage HBOT

Documentation Required

Document Each HBOT Session

Maintain a session record for every HBOT treatment, including physical findings and the treatment delivered.

Record ascent and descent time, total compression time, oxygen dose, pressurization level, attendance, and treatment events.

Documentation Required

Document Treatment Response

Document the effect of treatment on the established HBOT goals and use the response to support continuation or discontinuation.

Link each treatment response to the measurable goals documented at initiation.

Unsupported block type: documentation

Documentation Required

Document Patient Selection and Treatment Parameters

Document patient selection and the prescribed treatment parameters for the covered indication, including the clinical rationale for the selected pressure, frequency, duration, and treatment limit.

For nonhealing diabetic wounds, document Wagner grade 3 or higher and failure of standard wound therapy for at least 30 consecutive days.
Document the applicable utilization-review threshold, such as after 40 treatments for diabetic wounds, after 30–40 sessions for chronic osteomyelitis, after 30 treatments for necrotizing soft-tissue infection, and after 10–30 treatments for refractory mycosis.

Documentation Required

Document Practitioner Qualifications and Supervision

Ensure that HBOT is rendered under the required practitioner qualifications, supervision, availability, and emergency-readiness standards.

Qualified NPPs may supervise only within their scope of practice, with the required physician relationship and education.
Supervising physicians should meet recognized undersea and hyperbaric medicine certification or training criteria.
The physician must be present during ascent and descent when required; ACLS certification and immediate availability requirements also apply based on the site of service.

Denial Risk

Topical HBOT Is Investigational

Topical hyperbaric oxygen therapy is considered investigational and is not covered as medically necessary under this policy.

Do not substitute topical HBOT for covered systemic HBOT indications.

Denial Risk

All Diabetic Wound Criteria Must Be Met

For diabetic lower-extremity wounds, all coverage criteria must be met; failure of any required criterion may result in denial.

The wound must be due to diabetes and classified as Wagner grade 3 or higher.
There must be no measurable healing after 30 days of an adequate course of standard wound therapy.
Standard therapy must address applicable vascular problems, nutrition, glucose control, debridement, a clean moist granulation bed with appropriate dressings, off-loading, and infection treatment.
HBOT must be provided as an adjunct to continuing standard wound care.

Denial Risk

Unlisted Systemic HBOT Indications Are Investigational

Systemic HBOT in a pressurized chamber is considered investigational for indications other than those specifically identified as medically appropriate in the policy.

Examples include acute ischemic stroke and bone grafts.

Denial Risk

Expanded Investigational-Indication List

The policy identifies additional systemic HBOT uses as investigational, including chronic nonhealing wounds and Bell’s palsy.

Do not assume that a chronic or nonhealing wound is covered unless the applicable covered diabetic-wound criteria are satisfied.
Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis, is not covered.

Denial Risk

Hydrogen Sulfide Poisoning Is Not Covered

HBOT for hydrogen sulfide poisoning is not covered under this policy.

Denial Risk

Inflammatory Bowel Disease Is Not Covered

HBOT for inflammatory bowel disease, including Crohn’s disease and ulcerative colitis, is not covered.

Denial Risk

Interstitial Cystitis Is Not Covered

HBOT for interstitial cystitis is not covered under this policy.

Denial Risk

Intra-abdominal or Intracranial Abscesses Are Not Covered

HBOT for intra-abdominal or intracranial abscesses is not covered under this policy.

Denial Risk

In Vitro Fertilization Is Not Covered

HBOT for in vitro fertilization is not covered under this policy.

Denial Risk

Lepromatous Leprosy Is Not Covered

HBOT for lepromatous leprosy is not covered under this policy.

Denial Risk

Malignant Otitis Externa Is Not Covered

HBOT for malignant otitis externa is not covered under this policy.

Denial Risk

Meningitis Is Not Covered

HBOT for meningitis is not covered under this policy.

Denial Risk

Migraine Is Not Covered

HBOT for migraine is not covered under this policy.

Denial Risk

Myocardial Infarction or Acute Coronary Syndrome Is Not Covered

HBOT for myocardial infarction or acute coronary syndrome, including acute myocardial infarction and unstable angina, is not covered.

Denial Risk

Multiple Sclerosis Is Not Covered

HBOT for multiple sclerosis is not covered under this policy.

Denial Risk

Delayed-Onset Muscle Soreness Is Not Covered

HBOT for delayed-onset muscle soreness is not covered under this policy.

Denial Risk

Prevention of Coronary Restenosis Is Not Covered

HBOT for prevention of coronary restenosis is not covered under this policy.

Denial Risk

Pseudomembranous Colitis Is Not Covered

HBOT for pseudomembranous colitis, including antimicrobial agent-induced colitis, is not covered.

Denial Risk

Pyoderma Gangrenosum Is Not Covered

HBOT for pyoderma gangrenosum is not covered under this policy.

Denial Risk

Radiation Myelitis Is Not Covered

HBOT for radiation myelitis is not covered under this policy.

Denial Risk

Tumor Sensitization Use Is Not Covered

HBOT used with radiation therapy for tumor sensitization is not covered under this policy.

Denial Risk

Retinal Detachment Is Not Covered

HBOT for retinal detachment is not covered under this policy.

Denial Risk

Sickle Cell Peripheral Retinopathy Adjunctive Use Is Not Covered

Adjunctive HBOT for sickle cell peripheral retinopathy in connection with scleral buckling procedures is not covered.

Denial Risk

Insufficient Medical Necessity or Replacement of Standard Care

HBOT may be denied when the record does not establish medical necessity for the specific condition or when HBOT replaces successful standard therapeutic measures.

Document the condition being treated, the medical necessity of HBOT, prior and concurrent standard treatments, and their effectiveness.
HBOT must remain adjunctive to, rather than a replacement for, appropriate standard care.

Denial Risk

No Measurable Healing Within 30 Days

Continued HBOT for a diabetic wound is not covered when measurable signs of healing have not been demonstrated within any 30-day treatment period.

Most patients should not require more than 40 treatments; lack of response by 40 treatments generally does not support extending treatment to 60, 80, or 120 treatments.

Denial Risk

Unsuitable or Unsalvageable Diabetic Foot

Do not continue HBOT for a diabetic foot wound that is unsuitable or unsalvageable.

Use clinical assessment and, when appropriate, photographs to identify advanced wounds unlikely to respond, including a Wagner 5 foot with complete gangrene once the heel is necrotic.

Denial Risk

Discontinue When Treatment Goals Are Not Met

Discontinue diabetic-wound HBOT when the patient heals, cannot tolerate treatment, or fails to improve.

Document wound measurements, changes in wound condition, and progress toward the established treatment goals.

Prior Authorization

Utilization Review After 30–40 Osteomyelitis Sessions

Chronic osteomyelitis requiring more than 30–40 HBOT sessions must undergo utilization review.

HBOT is not a primary treatment; document surgical debridement and at least one appropriate six-week course of parenteral antibiotics.

Prior Authorization

Utilization Review After 30 Necrotizing-Infection Treatments

Necrotizing soft-tissue infection requiring more than 30 HBOT treatments must undergo utilization review.

HBOT is adjunctive and should be used only when morbidity and mortality remain high despite aggressive standard treatment.

Prior Authorization

Refractory Mycosis Utilization Review

Refractory mycosis requiring treatment beyond 10–30 sessions must undergo utilization review.

Document that HBOT is being provided with standard treatment and that the disease remains refractory.

Denial Risk

Unapproved Stroke or Uncleared Indication

Do not bill or request coverage for HBOT for acute ischemic stroke unless the indication is otherwise approved or the service is provided under an applicable exception such as a clinical trial or cerebral air embolism.

The policy considers acute ischemic stroke investigational.
An unapproved indication or an indication not cleared for the device may be denied.

Denial Risk

Autism Spectrum Disorder: Routine HBOT Not Supported

Routine HBOT for autism spectrum disorder is not supported by the evidence and is not a covered routine indication.

Available evidence has not demonstrated improvement in core or associated ASD symptoms compared with sham treatment.
The Undersea and Hyperbaric Medical Society does not recommend routine treatment of autism with HBOT.

Billing Rule

Benefit Exclusion or Limited Code Coverage

Coverage is subject to the member’s benefit contract, and codes may not be covered under all circumstances.

Verify the applicable product benefit before rendering or billing the service.
Medical policy criteria apply only when the product covers the service, subject to applicable Medicare or Medicaid coverage rules.

Billing Rule

A4575 and E0446 Are Investigational Topical Oxygen Codes

HCPCS codes A4575 and E0446 describe topical oxygen technologies and are classified as experimental/investigational under this policy.

A4575: Topical hyperbaric oxygen chamber, disposable.
E0446: Topical oxygen delivery system, not otherwise specified, including supplies and accessories.
Do not confuse these topical codes with G0277 for hyperbaric oxygen under pressure in a full-body chamber.

Systemic HBOT definition

ChamberPatient is entirely enclosed in a pressure chamber

OxygenBreathes nearly 100% oxygen intermittently

PressureGreater than one atmosphere

Topical HBOT definition

Oxygen delivery100% oxygen is delivered directly to a wound site

PressureSlightly higher than atmospheric pressure

Delivery methodAn appliance encloses the wound area and connects to a source of oxygen

CLTI definition

AbbreviationCLTI

Full termChronic limb-threatening ischemia

HBOT role describedA possible adjunct to revascularization for wound healing in this setting and diabetic foot ulcers

SSNHL definition

AbbreviationSSNHL

Full termSudden sensorineural hearing loss

Guideline timingHBOT combined with steroid therapy may be used within 2 weeks of onset or as salvage within 1 month

CRAO definition

AbbreviationCRAO

Full termCentral retinal artery occlusion

Clinical presentation describedSudden, usually painless visual loss caused by retinal arterial obstruction

E/I abbreviation

AbbreviationE/I

MeaningExperimental/Investigational

Use in policyIdentifies codes designated experimental or investigational

NMN abbreviation

AbbreviationNMN

MeaningNot medically necessary/appropriate

Use in policyIdentifies services designated not medically necessary or appropriate