Notification Issue Date:

Policy Attachment

Attachment to Policy # MA07.001a


Policy #:MA07.001a

Description:Recommended Utilization Guidelines for Medically necessary conditions using Hyperbaric Oxygen Therapy (HBO)

Title:Hyperbaric Oxygen Therapy

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

Utilization Guidelines

Utilization guidelines are presented relative to specific treatment conditions. The diagnosis should be established by the referring or treating professional provider prior to the initiation of HBO therapy.

Hyperbaric oxygen (HBO) therapy should not be a replacement for other standard successful therapeutic measures. Depending on the response of the individual and the severity of the original problem, treatment may range from less than 1 week to several months duration, the average being 2 to 4 weeks. The use of HBO therapy for more than 20 treatment sessions, or conditions being treated over the recommended treatment sessions, regardless of the condition of the individual, may be subject to review for medical necessity before further reimbursement is made.

Typical Dose
Utilization Review
Carbon monoxide poisoning, acuteUp to 3 ATA
1-3 sessions
3 treatments
Decompression sicknessUS Navy Treatment Table 6 or equivalent
1 to clinical plateau
10 treatments
Air or gas embolismUS Navy Treatment Table 6 or equivalent
1-2 sessions, or to clinical plateau
5 treatments
Clostridial myositis
Clostridial myonecrosis
2.4-3.0 ATA 3 times in first 24 hours
Twice daily for the next 2-5 days
15 treatments
Crush injury
Acute traumatic ischemia
2-2.4 ATA 2 times/day
2-7 days
15 treatments
Necrotizing soft tissue infection2-2.5 ATA
Twice daily until stabilization
10 treatments
Compromised skin grafts and flaps2-2.5 ATA
Twice daily up to 20 sessions
20 treatments
Refractory osteomyelitis2-3 ATA
20-40 sessions
60 treatments
over 12 months
Delayed radiation injury:
Soft tissue radionecrosis
Bony radionecrosis (osteoradionecrosis)
2-2.5 ATA
For radiation injury: 30 - 60 sessions
For prophylaxis: 20 sessions before surgery in radiated field
10 sessions after surgery

Every 30 days (continued treatment not indicaed if no improvement noted after two 30 day periods)
Actinomycosis2-3 ATA
20-40 sessions
60 treatments
over 12 months
Diabetic Foot Ulcer2-2.5 ATA
Daily for 3-4 weeks, based on healing response
Every 30 days

Version Effective Date: 12/01/2016
Version Issued Date: 12/01/2016
Version Reissued Date: 12/19/2019

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