Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Topical Oxygenation
Policy #:MA07.011a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Topical oxygenation is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, topical oxygenation is not eligible for payment under the medical benefits of the Company’s Medicare Advantage products because the service is considered experimental/investigational and, therefore, not covered.

Services that are experimental/investigational are excluded for the Company’s Medicare Advantage plans. Therefore, they are not eligible for reimbursement consideration.

Description

Topical oxygenation, also referred to as topical hyperbaric oxygenation, is a technique that delivers 100 percent oxygen directly to an open, moist wound at a pressure slightly higher than atmospheric pressure. The theory behind this therapy is that the high concentrations of oxygen diffuse directly into the wound to increase the local cellular tension, which in turn promotes wound healing. During topical oxygenation, a device surrounds the wound area (usually an extremity), and oxygen is delivered under pressure from a source such as a conventional oxygen tank. This therapy has been promoted as a treatment for diabetic and venous stasis ulcers, burns, amputations, infected wounds, frostbite, gangrenous lesions, and skin graft sites. Topical oxygenation may be performed in the inpatient, home, clinic, or office setting. Typically, the therapy is offered for 90 minutes per day for four consecutive days. After a three-day break, the cycle may be repeated.

Topical oxygenation has sometimes been confused with hyperbaric oxygen therapy (HBO), which involves the inhalation of 100 percent oxygen at an elevated (ie, greater than sea-level) atmospheric pressure, typically between 2 and 3 atmospheres absolute (ATA). The delivery system for HBO uses either a full-body monoplace (single-person) chamber or a full-body multiplace (multiple-person) chamber. In monoplace chambers, the entire chamber is pressurized with 100 percent oxygen to the desired ATA. Multiplace chambers, which can accommodate two to twelve individuals, are pressurized using compressed air; the individuals breathe 100 percent oxygen via mask, head tent, or endotracheal tube.

Clinical efficacy of topical oxygen has not been established.
References

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 20.29: Hyperbaric oxygen therapy. [CMS Web site]. 06/19/06. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=12&ncdver=4&bc=AAAAgAAAAAAA&. Accessed May 08, 2019.

Copeland K, Purvis AR. A retrospective chart review of chronic wound patients with topical oxygen therapy. Advances in Wound Care.2017; 6(5):143-152.

Hunt S. Topicaloxygenationtherapy in wound care: are patients getting enough? Br J Nurs.2017;26(15):S28-S36.

Novitas Solutions Inc. Medicare Local Coverage Determination (LCD). L35021 Hyperbaric Oxygen (HBO) Therapy. Original: 10/01/2015. (Revised 04/11/2019). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35021&ver=137&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Pennsylvania&KeyWord=Hyperbaric+Oxygen+Therapy&KeyWordLookUp=Title&KeyWordSearchType=And&FriendlyError=NoLCDIDVersion&bc=gAAAACAAAAAA&. Accessed May 08, 2019.

Yu J, Lu S, McLaren AM, et al. Topicaloxygen therapyresults in complete wound healing in diabetic foot ulcers. Wound Repair Regen.2016;24(6):1066-1072.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

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

CPT Procedure Code Number(s)

THE FOLLOWING CODE IS USED TO REPRESENT TOPICAL OXYGENATION WHEN PERFORMED AS A PROFESSIONAL SERVICE: 99199


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



THE FOLLOWING CODES ARE CONSIDERED EXPERIMENTAL/INVESTIGATIONAL:

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



Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

Revisions from MA07.011a
06/05/2019The policy has been reviewed and reissued to communicate the Company’s continuing position on topical oxygenation.
05/23/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on topical oxygenation.
06/07/2017This policy has been reissued in accordance with the Company's annual review process.
03/16/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on Topical Oxygenation.

Revisions from MA07.011a
04/08/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Topical Oxygenation. The CPT code 99199 added to policy.

Revisions from MA07.011
01/01/2015This is a new policy.





Version Effective Date: 04/08/2015
Version Issued Date: 04/08/2015
Version Reissued Date: 06/05/2019