CurrentPriority Health MedicarePolicy 91151

Hyperbaric Oxygen Therapy

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This policy establishes medical necessity criteria for systemic hyperbaric oxygen therapy for selected wound-related and non-wound indications, and identifies topical hyperbaric oxygen therapy and home hyperbaric oxygen chambers as excluded or not medically necessary.

Policy Summary

PayerPriority Health Medicare

PolicyHyperbaric Oxygen Therapy

Policy CodePolicy N/A

Change TypeNo material clinical or coverage change

Effective Date09/01/2026

Next Review DateN/A

Key ActionDocument the wound indication, classification, diabetes type when applicable, and at least 30 days of standard wound therapy without measurable healing when requesting adjunctive HBOT.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5Initial wound-related HBOT indications

3Adjunctive diabetic wound criteria

30 daysRequired standard therapy without measurable healing

2.0 ATAMinimum systemic HBOT chamber pressure

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CurrentPriority Health MedicarePolicy 91151

Hyperbaric Oxygen Therapy

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Sign up for priority_health_medicare Policy 91151 alerts

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Policy Summary

PayerPriority Health Medicare

PolicyHyperbaric Oxygen Therapy

Policy CodePolicy N/A

Change TypeNo material clinical or coverage change

Effective Date09/01/2026

Next Review DateN/A

Key ActionDocument the wound indication, classification, diabetes type when applicable, and at least 30 days of standard wound therapy without measurable healing when requesting adjunctive HBOT.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5Initial wound-related HBOT indications

3Adjunctive diabetic wound criteria

30 daysRequired standard therapy without measurable healing

2.0 ATAMinimum systemic HBOT chamber pressure

Typical HBOT treatment duration

2Excluded modalities or settings

Medical Necessity and Coverage Criteria

Non-wound related therapy

HBOT is medically necessary for any of the following non-wound indications when the applicable indication-specific conditions are met.

Covered non-wound indications

Actinomycosis is refractory to antibiotics and surgical treatment, and HBOT is used only as an adjunct to conventional therapy.
Acute carbon monoxide intoxication.
Acute peripheral artery insufficiency.
Central retinal artery occlusion.
Chronic refractory osteomyelitis is unresponsive to conventional medical and surgical management.
Cyanide poisoning.
Decompression illness.
Gas embolism.
Idiopathic sudden sensorineural hearing loss.
Osteoradionecrosis is treated as an adjunct to conventional treatment.
Soft tissue radionecrosis is treated as an adjunct to conventional treatment.

Initial wound therapy

Initial therapy is covered for any of the following wound-related indications.

Initial wound therapy indications

Compromised skin grafts: Preparation and preservation of compromised skin grafts, not for primary management of wounds.
Acute traumatic peripheral ischemia.
Crush injuries and suturing of severed limbs.
Gas gangrene.
Progressive necrotizing infections, including necrotizing fasciitis.

Adjunctive diabetic wound therapy

Adjunctive HBOT is covered only when all of the following requirements are met.

Adjunctive therapy prerequisites

Standard wound therapy: The patient has received standard wound therapy for at least 30 days without measurable signs of healing, and HBOT is used together with standard wound therapy.At least 30 days without measurable healing
Diabetic lower-extremity wound
- Diabetes and wound relationship: The patient has type 1 or type 2 diabetes and a lower-extremity wound due to diabetes.
- Wound classification: The wound is classified as Wagner grade III or higher.Wagner grade III or higher

Topical hyperbaric oxygen therapy is excluded from coverage because there is insufficient evidence that it accelerates wound healing, either when used alone or as an adjunct to standard wound care.

Home hyperbaric oxygen therapy chambers are excluded from coverage.

Experimental, investigational, or unproven treatment is excluded from coverage. Individual case review may allow coverage for investigational treatment that is promising for the applicable condition, but requests for individual consideration require prior plan approval. An exception may be reviewed when the condition is a terminal illness or a chronic, life-threatening, severely disabling disease causing serious clinical deterioration.

Mild hyperbaric oxygen therapy delivered at pressures lower than 1.5 ATA is unproven and is not covered as medically necessary under this policy.

Topical hyperbaric oxygen chambers and topical oxygen delivery systems are not medically necessary. This includes HCPCS A4575 (topical hyperbaric oxygen chamber, disposable) and E0446 (topical oxygen delivery system, not otherwise specified, including supplies and accessories).

Covered and Non-Covered Codes

Revenue codeRevenueCovered

0413	Hyperbaric Oxygen Therapy for Outpatient

Outpatient CPT/HCPCS CodesCPTCovered

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

Not Medically NecessaryHCPCSNot Covered

A4575	Topical hyperbaric oxygen chamber, disposable
E0446	Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories

Acute carbon monoxide intoxicationICD-10Covered

T58.01xA - T58.94xS

Toxic effect of carbon monoxide

Decompression illnessICD-10Covered

T70.29XA	Other effects of high altitude
T70.29XS	Other effects of high altitude
T70.3XXA - T70.3XXS	Caisson disease [decompression sickness]
T70.9XXA - T70.9XXS	Effect of air pressure and water pressure, unspecified

Gas embolismICD-10Covered

T79.0XXA - T79.0XXS	Air embolism (traumatic)
T80.0XXA - T80.0XXS	Air embolism following infusion, transfusion and therapeutic injection

Acute peripheral artery insufficiencyICD-10Covered

I70.231 - I70.249	Atherosclerosis of native arteries of leg with ulceration
I70.331 - I70.349	Atherosclerosis of unspecified type of bypass graft(s) of leg with ulceration
I70.431 - I70.469	Atherosclerosis of autologous vein bypass graft(s) of leg with ulceration
I70.531 - I70.549	Atherosclerosis of nonautologous biological bypass graft(s) of leg with ulceration
I70.631 - I70.669	Atherosclerosis of nonbiological bypass graft(s) of extremity with ulceration/gangrene
I70.731 - I70.769	Atherosclerosis of other type of bypass graft(s) of extremity with ulceration/gangrene
I74.2 - I74.5	Embolism and thrombosis of arteries
L97.101 - L97.929	Non-pressure chronic ulcer of lower limb

Chronic refractory osteomyelitisICD-10Covered

M86.30 - M86.69	Chronic osteomyelitis
M86.8X0 - M86.8X8	Other osteomyelitis

Osteoradionecrosis and soft tissue radionecrosisICD-10Covered

T66.XXXA - T66.XXXS	Radiation sickness, unspecified
M27.2	Inflammatory conditions of the jaw
M27.8	Other specified diseases of jaws
L59.8	Other specified disorders of the skin and subcutaneous tissue related to radiation
L59.9	Disorder of the skin and subcutaneous tissue related to radiation, unspecified

Cyanide poisoningICD-10Covered

T57.3X1A - T57.3X4S	Toxic effect of hydrogen cyanide, undetermined
T65.0X1A - T65.0X4S	Toxic effect of cyanides, accidental (unintentional)

ActinomycosisICD-10Covered

A42.0 - A42.9	Actinomycosis
A43.0 - A43.9	Nocardiosis
B47.1	Actinomycetoma
B47.9	Mycetoma, unspecified
L08.1	Erythrasma

Preparation and preservation of compromised skin graftsICD-10Covered

T86.820 - T86.829

Skin graft (allograft) rejection

Acute traumatic peripheral ischemia; crush injuries and suturing of severed limbsICD-10Covered

S07.0XXA - S07.9XXS	Crushing injury of head
S17.0XXA - S17.9XXS	Crushing injury of neck
S28.0XXA - S28.9XXS	Crushed injury of chest
S35.511A - S35.513S	Injury of iliac artery
S38.001A - S38.1XXS	Crushing injury of abdomen, lower back, pelvis and external genitals
S45.001A - S45.299S	Injury of axillary or brachial blood vessels
S47.1XXA - S47.9XXS	Crushing injury of shoulder and upper arm
S57.00XA - S57.82XS	Crushing injury of arm
S67.00XA - S67.92XS	Crushing injury of wrist, hand and fingers
S75.001A - S75.099S	Injury of femoral artery

1–10 of 16

1/2

Progressive necrotizing infectionsICD-10Covered

M72.6	Necrotizing fasciitis
M87.00 - M87.9	Idiopathic aseptic necrosis of bone
M90.50 - M90.59	Osteonecrosis in diseases classified elsewhere

Gas gangreneICD-10Covered

A48.0

Gas gangrene

Diabetic wounds of the lower extremitiesICD-10Covered

E08.50 - E08.59	Diabetes mellitus due to underlying condition with circulatory complications
E09.51 - E09.59	Drug or chemical induced diabetes mellitus with circulatory complications
E10.51 - E10.59	Type 1 diabetes mellitus with circulatory complications
E10.618	Type 1 diabetes mellitus with other diabetic arthropathy
E10.620	Type 1 diabetes mellitus with diabetic dermatitis
E10.621	Type 1 diabetes mellitus with foot ulcer
E10.622	Type 1 diabetes mellitus with other skin ulcer
E10.628	Type 1 diabetes mellitus with other skin complications
E10.65	Type 1 diabetes mellitus with hyperglycemia
E10.69	Type 1 diabetes mellitus with other specified complication

1–10 of 26

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Irradiation cystitisICD-10Covered

N30.40	Irradiation cystitis without hematuria
N30.41	Irradiation cystitis with hematuria

Idiopathic sudden sensorineural hearing lossICD-10Covered

H91.20 - H92.23

Sudden idiopathic hearing loss

Standard wound therapy before adjunctive HBOT

Minimum treatment periodAt least 30 days of standard wound therapy

Healing requirementNo measurable signs of healing during the treatment period

Use with HBOTAdjunctive HBOT must be used together with standard wound therapy

Authorization, Documentation, and Denial Risks

Prior Authorization

Verify Prior Authorization and Individual Consideration

Check whether prior authorization is required for the requested HBOT service and use Priority Health Prism (Authorizations → Authorization Criteria Lookup) to access applicable EviCore, InterQual, or TurningPoint criteria. Individual consideration may be available for investigational but promising treatment, but requires prior plan approval and review by a Priority Health medical director or clinical pharmacist.

Submit requests according to the Priority Health Provider Manual when prior authorization applies.
Exception review for experimental, investigational, or unproven treatment is limited to cases involving terminal illness or chronic, life-threatening, severely disabling disease with serious clinical deterioration.

Denial Risk

Prevent Denial for Diabetic Wounds

For diabetic lower-extremity wound HBOT, document that all required criteria are met. Coverage is at risk when any criterion is absent or not supported in the record.

Therapy Background

Systemic hyperbaric oxygen therapy (HBOT) places the entire patient in a hard-sided pressure chamber and delivers prescribed medical-grade oxygen at a pressure greater than atmospheric pressure. The increased pressure allows oxygenated blood to reach target tissues; the policy describes typical treatment pressures of 1.9 to 3.0 ATA, with a systemic chamber pressure of not less than 2.0 ATA (202.65 kPa). Treatment commonly lasts 90 to 120 minutes per session.

Key Terms

Systemic hyperbaric oxygen therapy

ProcedureThe patient is entirely enclosed in a pressure chamber

Oxygen deliveryThe patient breathes medical-grade oxygen

PressurePressure greater than one atmosphere

Treatment characteristicsSystemic circulation delivers highly oxygenated blood to the target site

Topical hyperbaric oxygen therapy

Oxygen delivery100% oxygen is delivered directly to an open, moist wound

Delivery methodA limb-encasing device

Policy Summary

PayerPriority Health Medicare

PolicyHyperbaric Oxygen Therapy

Policy CodePolicy N/A

Change TypeNo material clinical or coverage change

Effective Date09/01/2026

Next Review DateN/A

Key ActionDocument the wound indication, classification, diabetes type when applicable, and at least 30 days of standard wound therapy without measurable healing when requesting adjunctive HBOT.

SourceLink

On This Page

Failed standard wound therapy: The patient has failed an adequate course of standard wound therapy.

Diabetic wound classification

Required classificationWagner grade III or higher

Diabetes requirementType 1 or type 2 diabetes

Wound requirementLower-extremity wound due to diabetes

Systemic HBOT chamber pressure

Minimum chamber pressureNot less than 2.0 ATA

Equivalent pressure202.65 KPa

Treatment oxygenPhysician-prescribed medical-grade oxygen

Typical treatment duration90-120 minutes per treatment

Mild hyperbaric oxygen pressure

Pressure thresholdLower than 1.5 ATA

Oxygen concentrationGas mixes well less than 95% O2; breathing devices may further reduce oxygen concentration

Treatment settingAvailable outside medical facilities, including physicians' offices, wellness centers, and health spas

Evidence statusUnproven

The patient has type 1 or type 2 diabetes and a lower-extremity wound due to diabetes.
The wound is classified as Wagner grade III or higher.
The patient failed an adequate course of standard wound therapy.
HBOT is adjunctive and must be used with standard wound therapy after no measurable healing for at least 30 days of treatment.

Documentation Required

Document the Covered Indication

Document the specific covered diagnosis and the indication-specific circumstances supporting HBOT for non-wound and wound-related conditions. The record should establish the diagnosis and any required adjunctive or refractory-treatment status.

Covered non-wound indications include acute carbon monoxide intoxication, acute peripheral artery insufficiency, central retinal artery occlusion, chronic refractory osteomyelitis unresponsive to conventional medical and surgical management, cyanide poisoning, decompression illness, gas embolism, idiopathic sudden sensorineural hearing loss, osteoradionecrosis as an adjunct to conventional treatment, and soft tissue radionecrosis as an adjunct to conventional treatment.
Covered initial wound indications include compromised skin graft preparation or preservation, acute traumatic peripheral ischemia, crush injuries or sutured severed limbs, gas gangrene, and progressive necrotizing infections.
For adjunctive wound indications, document the required 30-day course of standard wound therapy with no measurable healing.

Documentation Required

Confirm Physician Oversight and Treatment Setting

Ensure HBOT is prescribed and supervised by a physician and delivered in an appropriate medical treatment setting. The patient must be entirely enclosed in a compliant hard-sided chamber rather than treated with a topical or mild-hyperbaric device.

Use a hard-sided chamber meeting ASME-PVHO-1 and NFPA 99 standards for hyperbaric chambers.
Treatment pressure must be at least 2.0 ATA while the patient breathes physician-prescribed medical-grade oxygen.
Treatment is typically 90–120 minutes; use a hospital or properly inspected and accredited facility when available.

Documentation Required

Submit Medical-Necessity Documentation

When prior authorization is required, submit documentation demonstrating that the requested HBOT is medically necessary and satisfies the applicable Priority Health or delegated-entity criteria.

Include the diagnosis, indication-specific criteria, treatment history, standard wound therapy history when applicable, and the proposed treatment setting and prescription.
Use Priority Health Prism’s Authorization Criteria Lookup and follow the Priority Health Provider Manual.

Denial Risk

Diabetic Wound Criteria Not Met

Diabetic lower-extremity wound HBOT may be denied when the patient does not have diabetes-related lower-extremity disease, the wound is below Wagner grade III, or an adequate course of standard wound therapy has not failed.

Do not submit adjunctive HBOT without documentation of all three diabetic-wound criteria.
Also document no measurable healing for at least 30 days and continued use of standard wound therapy.

Denial Risk

Document Failed Standard Wound Therapy

Adjunctive wound HBOT is not supported when the record does not show at least 30 days of standard wound therapy without measurable healing. Standard wound therapy must continue during HBOT.

Document the therapies provided, treatment duration, and objective wound measurements demonstrating absent measurable healing.
Failure to establish an adequate standard-therapy course creates a denial risk.

Denial Risk

Avoid Excluded HBOT Modalities

Topical HBOT and home HBOT chambers are excluded or not medically necessary under the policy. These approaches are not equivalent to systemic HBOT delivered in a compliant monoplace or multiplace chamber.

Topical oxygen delivered in a limb-encasing device lacks sufficient evidence to demonstrate accelerated wound healing.
Home chambers and mild HBOT delivered below 1.5 ATA, including treatment outside appropriate medical facilities, are not the covered systemic HBOT setting.

Denial Risk

Verify Indication-Specific Conditions

For indication-specific coverage, document that the required disease status and treatment relationship are present. Actinomycosis is covered only as adjunctive treatment when refractory to antibiotics and surgical treatment; other listed indications also require the applicable refractory, unresponsive, or adjunctive conditions.

For chronic refractory osteomyelitis, show unresponsiveness to conventional medical and surgical management.
For osteoradionecrosis and soft tissue radionecrosis, document use as an adjunct to conventional treatment.
For initial wound indications, document the qualifying acute injury, infection, ischemia, graft, or limb-repair condition.

Denial Risk

Experimental or Unproven Treatment Exclusion

Do not assume coverage for experimental, investigational, or unproven HBOT. Such treatment is excluded unless an approved individual-case exception applies.

Any exception requires prior plan approval and determination by a Priority Health medical director or clinical pharmacist.
Exception review may be requested when the condition is terminal or is chronic, life-threatening, severely disabling, and causing serious clinical deterioration.

Pressure contextPressure slightly higher than atmospheric pressure

Relation to systemic HBOTNot equivalent to monoplace or multiplace chamber systemic HBOT

Mild hyperbaric oxygen therapy

PressureExposures delivered at pressures lower than 1.5 ATA

Oxygen concentrationGas mixes well less than 95% O2; masks and ambient chamber air may further reduce oxygen concentration

SettingAvailable outside medical facilities, including physicians' offices, wellness centers, and health spas

SupervisionGenerally not physician-prescribed or supervised

Wagner grade III or higher

Required wound classificationWagner grade III or higher

Applicable conditionDiabetic lower-extremity wound

Diabetes requirementThe patient has type 1 or type 2 diabetes and the wound is due to diabetes

Therapy contextAdjunctive HBOT is used only after an adequate course of standard wound therapy has failed