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Coverage criteria policies

Hyperbaric oxygen therapy

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for hyperbaric oxygen therapy.

Coverage

Hyperbaric oxygen therapy is generally covered subject to the indications listed below and per your plan documents.

HealthPartners follows recommendations from the Undersea Hyperbaric Medical Society.

Indications that are covered

  1. Acute traumatic peripheral ischemia
  2. Acute carbon monoxide intoxication
  3. Air or Gas embolism
  4. Arterial Insufficiencies
  5. Clostridial Myositis and Myonecrosis (Gas Gangrene)
  6. Compromised Grafts and Flaps
  7. Crush injuries and suturing of severed limbs
  8. Cyanide poisoning
  9. Decompression illness
  10. Delayed Radiation Injury (Soft Tissue and Bony Necrosis)
  11. Idiopathic Sudden Sensorineural hearing loss (ISSHL) (when used within two weeks of symptom onset)
  12. Intracranial Abscess
  13. Necrotizing Soft Tissue Infections
  14. Osteomyelitis (Refractory)
  15. Osteoradionecrosis
  16. Severe Anemia as indicated by exceptional blood loss and only when transfusion is impossible or delayed
  17. Wagner grade III or higher diabetic wounds/ulcers of the lower extremities that have failed standard wound therapy

Indications that are not covered

  • The use of topical hyperbaric oxygen therapy for all indications is considered investigative due to a lack of evidence demonstrating an impact on improved health outcomes
  • The use of systemic hyperbaric oxygen therapy for all indications other than those listed above is considered investigative due to lack of evidence demonstrating an impact on improved health outcomes.

Services that are considered to be investigational/experimental are not covered. The provider and facility will be liable for payment unless:

  1. The provider notifies the member that a specific service has been determined by HealthPartners to be investigational/experimental,
  2. The member signs a waiver agreeing to pay for the specific non-covered service being rendered and
  3. The claims has been billed with a GA modifier indicating such. If the member has signed a waiver agreeing to pay for the specific service then the member will be liable for payment.

Definitions

Hyperbaric oxygen therapy is a medical treatment in which the patient breathes 100% oxygen while inside a chamber at increased atmospheric pressure.

The Wagner grading scale is a widely used scale used to grade diabetic ulcers. These classification grades are:

  • Grade 0: No ulcer
  • Grade I: The ulcer is superficial which does not extend into the deeper tissues
  • Grade II: The ulcer is deep and extends to the tendon or ligament, no bone, involvement
  • Grade III: The ulcer is deep and contains an abscess or osteomyelitis, or both
  • Grade IV: The ulcer has led to localized gangrene
  • Grade V: The ulcer has caused gangrene of the entire foot

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

99183

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

C1300

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

G0277

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

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Armstrong, D., Alsa, R. and McCullough, D. Management of diabetic foot ulcers. In: UpToDate, Eidt, J., Mills, J. and Nathan, D. (Ed), UpToDate, Waltham, MA. (Accessed on March 23, 2018).
  2. Indications for Hyperbaric Oxygen Therapy - Undersea and Hyperbaric Medical Society. (n.d.). Indications for Hyperbaric Oxygen Therapy - Undersea and Hyperbaric Medical Society, 13th edition, 2014. Retrieved March 23, 2018 from http://membership.uhms.org/?page=indications
  3. Hayes, Inc. Hayes Medical Technology Directory Report. Hyperbaric Oxygen Therapy for Burns, Infections, and Nondiabetic Wounds. Lansdale, PA: Hayes, Inc.; Sept 2008. Reviewed Aug, 2012/Archived Oct, 2013.
  4. Mechem, C. and Manaker, S. Hyperbaric Oxygen Therapy. In: UpToDate, Traub, S. (Ed), UpToDate, Waltham, MA. (Accessed on March 23, 2018).

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Policy activity

  • 01/01/1994 - Date of origin
  • 03/01/2017 - Effective date
Review date
  • 03/2018
Revision date
  • 07/06/2016

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