Premera Bluecross Hyperbaric Oxygen Therapy Coverage

Coverage and Medical Necessity Criteria

Medically Necessary Indications (Systemic HBOT)

Systemic HBOT is considered medically necessary for the following conditions when applicable criteria are met:

Listed conditions: Acute traumatic ischemia (eg, crush injuries, reperfusion injury, compartment syndrome); Anemia from exceptional blood loss when transfusion is impossible or must be delayed; Acute carbon monoxide poisoning; Central retinal artery occlusion (CRAO); Compromised skin grafts or flaps; Acute cyanide poisoning; Decompression sickness; Acute gas embolism; Gas gangrene (clostridial myonecrosis); Idiopathic sudden sensorineural hearing loss (ISSNHL); Necrotizing soft tissue infections; Non-healing diabetic lower extremity wounds in individuals who meet all three diabetic-specific criteria (1) diagnosis of type 1 or type 2 diabetes with a lower-extremity wound due to diabetes; (2) wound classified as Wagner grade III or higher; and (3) no measurable signs of healing after 30 days of an adequate course of standard wound therapy; Chronic refractory osteomyelitis; Pre- and post-treatment for dental surgery of an irradiated jaw (non-implant); Soft tissue radiation necrosis (eg, radiation enteritis, cystitis)

Each listed condition is an independent medically necessary indication when the clinical criteria in the policy are satisfied.

Investigational Indications (Systemic and Topical HBOT)

Topical HBOT and other uses are considered investigational:

Investigational list: Topical hyperbaric oxygen therapy is investigational. Systemic or topical HBOT is investigational for indications including but not limited to: acute peripheral arterial insufficiency (when not meeting medically necessary criteria), acute coronary syndromes and adjunct to coronary interventions, acute ischemic stroke, acute osteomyelitis, acute surgical and traumatic wounds not meeting the medically necessary criteria, acute thermal burns, autism spectrum disorder, Bell's palsy, bisphosphonate-related osteonecrosis of the jaw, bone grafts, brown recluse spider bites, carbon tetrachloride poisoning, cerebral edema, cerebral palsy, chronic arm lymphedema post-radiotherapy, chronic wounds other than specified diabetic wounds, demyelinating diseases, fibromyalgia, fracture healing, herpes zoster, hydrogen sulfide poisoning, idiopathic femoral neck necrosis, inflammatory bowel disease, intra-abdominal and intracranial abscesses, lepromatous leprosy, meningitis, mental illness (eg, PTSD, anxiety, depression), migraine, motor dysfunction associated with stroke, pseudomembranous colitis, pyoderma gangrenosum, radiation myelitis, radiation-induced injury in the head and neck (except specified indications), refractory mycoses, retinopathy adjuncts, sickle cell crisis/hematuria, spinal cord injury, traumatic brain injury, tumor sensitization, and other conditions listed in the investigational sections of the policy.

See policy investigational list for full detail.

Coverage stance by indication

Coverage conclusions indicated by strength of evidence in the review:

Indications with sufficient evidence: Chronic diabetic foot ulcers: randomized trials and meta-analyses demonstrate higher healing rates with systemic HBOT and some analyses show reduced major amputation; evidence judged sufficient to show improvement in net health outcome.

Indications with sufficient evidence: Radiation-related injuries (radionecrosis/osteoradionecrosis and treatment of an irradiated jaw): RCTs and meta-analysis data support improved outcomes; evidence judged sufficient.

Indications with insufficient evidence: Topical HBOT for wounds, burns, and infections: trials heterogeneous and insufficient to determine improvement in net health outcome.

Indications with insufficient evidence: Carbon monoxide poisoning: Cochrane meta-analysis of low-quality RCTs did not show reduced risk of neurologic deficits; evidence insufficient.

Adjunctive HBOT for diabetic foot ulcers

Medicare and specialty society–aligned criteria for adjunctive systemic HBOT in diabetic foot ulcers

Medicare criteria for HBOT in diabetic lower extremity wounds: Coverage provided when ALL of the following are met: (1) patient has type I or type II diabetes with a lower-extremity wound due to diabetes; (2) wound is classified as Wagner grade III or higher; and (3) patient has failed an adequate course of standard wound therapy defined as no measurable signs of healing for at least 30 consecutive days. HBOT must be used as an adjunct to standard wound care and wounds must be evaluated at least every 30 days during therapy; continued HBOT is not covered if measurable signs of healing are not demonstrated within any 30-day treatment period.

Reflects Medicare national coverage criteria as stated in the policy.

Society guideline alignment

Society guidance for diabetic foot ulcers (UHMS and Society of Vascular Surgery collaborations)

Society guidance conditions: UHMS suggests against HBOT for Wagner grade 2 or lower diabetic foot ulcers and suggests adding HBOT for Wagner grade 3 or higher diabetic foot ulcers that have not shown significant improvement after 30 days of standard care; UHMS also suggests adding postoperative HBOT for Wagner grade 3 or higher ulcers after foot surgery. The Society for Vascular Surgery recommends adjunctive HBOT for diabetic foot ulcers that fail to improve (eg, <50% area reduction) after a minimum of four weeks (approximately 30 days) of standard wound therapy. Guideline strength varies by recommendation.30 days or 4 weeks

Guideline language summarized from UHMS and society statements in the policy.

This policy distinguishes between systemic and topical hyperbaric oxygen therapy (HBOT). Topical HBOT devices (e.g., HCPCS code A4575) and topical hyperbaric approaches are addressed by the policy but remain investigational. The policy does not address non-pressurized topical oxygen wound care. Systemic HBOT delivered in a pressurized chamber is evaluated separately for established medically necessary indications.

Clinical input received during prior reviews noted enthusiasm from specialty societies and academic centers for several indications (for example, compromised skin grafts/flaps and necrotizing soft tissue infections). However, reviewers also acknowledged a paucity of randomized trial data. After balancing clinical input with available evidence, compromised skin grafts/flaps and necrotizing soft tissue infections were considered but remain classified as investigational because published evidence is limited.

Topical hyperbaric oxygen therapy is not covered for any indication. In addition, systemic HBOT is not covered for indications other than those specified as medically necessary in this policy and per Medicare national coverage guidance.

Historical coding and policy updates have removed certain codes and legacy diagnosis codes from adjudication. Notably, topical HBOT device coding has changed over time and the portable topical oxygen device code (E0446) was moved to a non-covered/experimental policy in the document history. The policy also clarifies that topical HBOT (e.g., A4575) is investigational.

HBOT for conditions listed in the investigational sections of this policy is considered not medically necessary (investigational) and therefore not covered. The investigational list includes, but is not limited to, acute ischemic stroke, autism spectrum disorder, chronic wounds other than specified diabetic wounds, and many other neurologic, musculoskeletal, infectious, and systemic conditions.

Clinical input and guideline statements support classifying HBOT for autism spectrum disorder and for headache/migraine as investigational. Specialty reviewers and the American Academy of Pediatrics have advised that clinical trials do not support HBOT for ASD and caution against its use due to lack of supporting data and safety concerns.

Controlled trials and guideline reviews do not support HBOT for several neurologic conditions. For example, guideline statements conclude there is no demonstrated benefit for acute ischemic stroke (except for cerebral air embolism), and VA/DoD guidance recommends against HBOT for symptoms attributed to mild traumatic brain injury. These data contributed to listing many neurologic indications as investigational.

Over the policy history, specific conditions previously listed were deleted or reclassified when evidence did not support medical necessity. Historical edits include deletion of some conditions (for example, cerebral edema and refractory mycosis) as no longer medically necessary, reflecting evolving evidence and periodic policy updates.

Codes, Billing, and Clinical Thresholds

HBOT related CPT/HCPCS Codesmixed

99183	Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session
G0277	Hyperbaric oxygen under pressure, full body chamber, per 30-minute interval
A4575	Topical hyperbaric oxygen chamber, disposable

Coding - no explicit codes in this sectionmixed

Not listed in this excerpt

No explicit CPT/HCPCS/ICD-10 codes provided in this document segment.

HCPCS codes mentioned in historyHCPCS

G0277	HCPCS code added to the policy (effective 1/1/15)
A4575	HCPCS code added/removed at times per history
E0446	HCPCS code added on 12/01/24 then removed 01/01/26 and moved to non-covered policy

Legacy diagnosis codes mentionedICD-9

93.95

ICD-9 code removed per mapping project; not utilized for adjudication

Wagner grade threshold — diabetic lower extremity wounds

Wagner grade thresholdWagner grade 3 or higher for diabetic lower extremity wounds

ContextRequired as one of three Medicare-aligned criteria for adjunctive systemic HBOT in diabetic lower extremity wounds

Source guidanceReferenced in Medicare national coverage and UHMS guidance for diabetic foot ulcers

Standard wound therapy duration

Standard wound therapy durationNo measurable signs of healing after 30 days of an adequate course of standard wound therapy

Standard wound therapy elementsAssessment/optimization of vascular status, glycemic/nutritional optimization, debridement, moist dressings, off‑loading, infection treatment

Evaluation frequencyWounds must be evaluated at least every 30 days during HBOT

Failure of standard wound therapy (operational definition)

Operational definition of failureNo measurable signs of healing for at least 30 consecutive days

Implication for coverageFailure as defined must be documented before adjunctive systemic HBOT is authorized

Continued treatment ruleContinued HBOT is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment

Wagner grade threshold (alternate citation)

Alternate phrasingWagner grade III or higher cited as the minimum severity for adjunctive HBOT consideration

AlignmentStated in Medicare national coverage and UHMS recommendations

Role in criteriaOne of three required criteria (diabetes diagnosis, Wagner grade III+, and failed standard therapy) for Medicare coverage of adjunctive HBOT

Authorization, Documentation, and Administrative Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for requests that bill hyperbaric oxygen therapy (HBOT) CPT/HCPCS codes (for example, physician attendance/supervision 99183; chamber treatment G0277; topical chamber A4575) for dates of service on or after the policy effective date. Obtain prior authorization before initiating HBOT when coverage is being requested under the medically necessary indications in this policy.

Affected codes include, but are not limited to: CPT 99183; HCPCS G0277; HCPCS A4575.
Verify prior authorization requirements and obtain approval prior to scheduling HBOT.

Prior Authorization

Guideline-Informed Prior Authorization Considerations

Use guideline context when assessing prior authorization requests. When HBOT is requested as adjunctive therapy (for example, in chronic limb-threatening ischemia or diabetic foot ulcers), consider whether guideline-recommended standard interventions and specialist management have been attempted or are planned alongside HBOT.

ACC/AHA (2024) notes HBOT may be considered as an adjunct to revascularization for CLTI/diabetic foot ulcers.
Requests for HBOT as an adjunct should document coordination with vascular/surgical care when applicable.

Documentation Required

Required Clinical Documentation

Medical record documentation must demonstrate that medical necessity criteria are met for the requested HBOT. Include clear clinical evidence to support the indication and the need for HBOT.

Documented diagnosis and history & physical detailing severity.
For non-healing diabetic wounds: Wagner ulcer grade and documentation of prior therapies attempted.

Documentation Required

Documentation Must Demonstrate Failure of Standard Wound Therapy (>= 30 days)

Documentation must specifically demonstrate failure of an adequate course of standard wound therapy before adjunctive systemic HBOT for diabetic lower-extremity wounds will be authorized. Failure is defined operationally as no measurable signs of healing after at least 30 consecutive days of standard wound care.

Record wound measurements and progress notes across the 30-day trial period.
If requesting continuation, provide 30-day interval wound evaluations showing measurable healing; continued treatment is not covered if no measurable signs of healing are demonstrated within any 30-day treatment period.

Documentation Required

Prerequisite Standard Wound Therapy

Before HBOT is considered for diabetic foot wounds, an adequate course of standard wound therapy must have been provided. Standard wound therapy includes vascular assessment and correction if possible, debridement, off-loading, infection control, glycemic and nutritional optimization, and maintenance of a clean, moist wound bed.

Assessment of vascular status and correction of vascular problems when feasible.
Optimization of glycemic control and nutritional status.
Debridement, topical wound care, off-loading/pressure reduction, and treatment of infection.

Prior Authorization

Adjunctive Use After Standard Interventions

HBOT should be used only as an adjunct after standard interventions have failed to produce measurable healing. For conditions such as CLTI or diabetic foot ulcers, authorization should reflect that HBOT is adjunctive to, not a replacement for, revascularization or other definitive vascular/surgical treatments when indicated.

Document plans for or attempts at revascularization when applicable for CLTI.
Indicate how HBOT will be integrated with ongoing standard wound care and specialty interventions.

Note

Guideline References and Evidence Gaps

Guidelines identify evidence gaps and the need for standardized HBOT protocols and outcome measures. When submitting requests, include treatment protocols and measurable outcome plans where available to address these evidence gaps.

AAO-HNS notes the need for standardized HBOT treatment protocols and outcome assessments (SSNHL).
Provide protocol details (dose, chamber type, session length/frequency) and planned wound measurement methods when applicable.

Note

Verify Member Benefits

Providers should verify member benefits and any contract-specific limits prior to requesting authorization. This policy is a clinical guideline and coverage is subject to the member's benefit booklet and plan contract.

Check member benefit booklet or contact member services to confirm coverage, prior authorization requirements, and any quantity or site-of-service limits.
Policy does not apply to Medicare Advantage — verify applicable plan rules.

Note

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Definitions and Key Terms

Systemic vs Topical HBOT — definitions

Systemic HBOT definitionPatient is placed in a sealed chamber and breathes 100% oxygen at increased pressure (typically 1.5–3.0 atmospheres) to deliver oxygen systemically

Topical (local) HBOT definitionAn appliance (e.g., sleeve) encloses the wound area and delivers high‑concentration oxygen locally at slightly above atmospheric pressure to the isolated limb or wound

Key distinctionSystemic HBOT increases blood oxygen content for whole‑body delivery; topical HBOT increases local tissue oxygen tension at the wound site

Wagner ulcer grade (0–5)

Wagner ulcer grade scaleGrading system 0–5: 0=no open lesion; 1=superficial ulcer; 2=ulcer penetrates to tendon/bone/joint; 3=penetration with abscess/osteomyelitis/infection of tendon sheaths; 4=forefoot gangrene; 5=whole foot gangrene

Use in policyWagner grade is used to classify diabetic lower extremity wounds for HBOT eligibility

Documentation requirementMedical records should document the Wagner ulcer grade for non‑healing diabetic wounds

Topical hyperbaric oxygen therapy — label

Topical HBOT (label)Topical hyperbaric oxygen therapy: local application of 100% oxygen to an isolated wound area at slightly above atmospheric pressure (sleeve or enclosure)

Typical device useDevices may be disposable and used without supervision in the home by trained individuals

Evidence stanceInvestigational for improved net health outcomes

Systemic hyperbaric oxygen therapy — label

Systemic HBOT (label)Systemic hyperbaric oxygen therapy: patient breathes 100% oxygen inside a hyperbaric chamber at elevated pressure (commonly 1.5–3.0 atmospheres)

Intended effectIncreases arterial and tissue oxygen tensions to promote healing and treat certain systemic conditions

Regulatory noteFDA has cleared chambers for several indications including non‑healing diabetic foot ulcers

Wagner grade III+ diabetic foot ulcer — severity criterion

Coverage criterionWagner grade III or higher diabetic foot ulcer is defined as the severity criterion for considering adjunctive systemic HBOT

Policy rolePart of the three required Medicare‑aligned criteria for HBOT in diabetic lower extremity wounds

Supporting sourcesReferenced in Medicare national coverage statement and UHMS guidance

Systemic HBOT — Medicare coverage definition and scope

Medicare-covered systemic HBOTHBOT administered in a chamber for specified indications (including diabetic lower extremity wounds meeting criteria) when all clinical criteria are met

ScopeIncludes conditions listed in Medicare National Coverage (e.g., chronic refractory osteomyelitis, gas gangrene, decompression illness, select diabetic wounds)

Adjunctive requirementFor diabetic wounds, HBOT is covered only as adjunctive therapy after failure of standard wound therapy for at least 30 days

Topical HBOT — definition and coverage note

Topical HBOT statusTopical hyperbaric oxygen therapy: local application devices; explicitly noted as not covered by Medicare for any indication in this policy

Coding noteHCPCS A4575 describes a disposable topical hyperbaric oxygen appliance (mentioned as investigational)

Evidence stanceInvestigational — insufficient evidence to determine improved net health outcomes

CMS NCD 20.29 — reference

CMS NCD 20.29 referenceCMS National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29) cited as relevant coverage guidance

RoleMedicare national coverage criteria for diabetic wounds and other HBOT indications are based on NCD 20.29 (updated 2017)

Reference linkCMS NCD referenced in policy references (CMS NCD 20.29) for authoritative coverage details

Policy History and Revision Timeline

2026-05-01Annual Review / ApprovalLatest

Annual review approved April 13, 2026; policy updated with literature through December 8, 2025 and references added; policy statements unchanged.

2026-01-01Annual Review / Coding Update

Annual review approved December 22, 2025; removed HCPCS code E0446 from this policy and moved it to Non-Covered/Experimental policy 10.01.533; policy statements unchanged.

2024-12-01Annual Review / Coding Addition

Annual review approved November 11, 2024; policy updated with literature through June 7, 2024; added HCPCS code E0446 for topical hyperbaric oxygen therapy and removed requirement that HBOT be initiated within 24 hours of CRAO symptom onset.

2023-09-01Annual Review

Annual review approved August 21, 2023; policy updated with literature through April 28, 2023 and wording standardized from 'patient' to 'individual'; policy statements unchanged.

2022-10-01Interim Review / Coverage Change

Interim review approved September 13, 2022; changed policy statements to make HBOT medically necessary for compromised skin grafts and flaps and necrotizing soft tissue infections.

2022-08-01Interim Review / Coverage Change

Interim review approved July 12, 2022; changed policy statement for idiopathic sudden sensorineural hearing loss from investigational to medically necessary.

2022-04-01Annual Review / Renumbering

Annual review approved March 8, 2022; policy renumbered to 2.01.505 and updated with literature through November 30, 2021; added central retinal artery occlusion to medically necessary conditions.

2021-04-01Annual Review

Annual review approved March 2, 2021; policy updated with literature through November 14, 2020 and HCPCS code A4575 was added; policy statements unchanged.

2020-06-10Interim Review / Administrative

Interim review approved June 9, 2020 (effective June 10, 2020); referenced InterQual criteria for dates of service on or after July 2, 2020.

2013-10-14Replace Policy / Literature Update

Policy replaced and updated with literature review; coding updates noted December 3, 2013; no change in policy statement at that time.

1997-05-05New Policy

Policy added to Medicine Section as a new policy.

OpenPayer

Hyperbaric Oxygen Therapy

Coverage and Medical Necessity Criteria

Codes, Billing, and Clinical Thresholds

Authorization, Documentation, and Administrative Actions

Background and Clinical Overview

Definitions and Key Terms

Policy History and Revision Timeline