Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Hyperbaric Oxygen Therapy
Policy #:MA07.001a

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.

MEDICALLY NECESSARY

Full-body hyperbaric oxygen (HBO) therapy is considered medically necessary and, therefore, covered when both the Medical Requirements and the Technical Requirements, as listed below, are met.

MEDICAL REQUIREMENTS
Hyperbaric oxygen (HBO) therapy is considered medically necessary and, therefore, covered for any of the following indications:
  • Acute carbon monoxide intoxication
  • Decompression illness
  • Air or gas embolism
  • Gas gangrene (clostridial myositis or clostridial myonecrosis)
  • Acute traumatic peripheral ischemia , when all of the following criteria are met:
    • in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened
    • within the first 4-6 hours of the acute event, or for edema or after effects of acute arterial insufficiency if they are persistent after reconstructive surgery has restored large vessel function and perfusion
    • after documented restoration of the blood circulation
  • Crush injuries and suturing of severed limbs, when all of the following criteria are met:
    • in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened
    • within the first 4-6 hours of the acute event, or for edema or after effects of acute arterial insufficiency if they are persistent after reconstructive surgery has restored large vessel function and perfusion
    • after documented restoration of the blood circulation
  • Progressive necrotizing infections (necrotizing fasciitis) as an adjunct to surgical debridement and systemic antibiotics in settings where mortality and morbidity are expected to be high
  • Acute peripheral arterial insufficiency associated with arterial embolism and thrombosis, when all of the following criteria are met:
    • in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened
    • within the first 4-6 hours of the acute event, or for edema or after effects of acute arterial insufficiency if they are persistent after reconstructive surgery has restored large vessel function and perfusion
    • after documented restoration of the blood circulation
  • Preparation and preservation of compromised skin grafts, when all of the following criteria are met:
    • as salvage in cases where hypoxia or decreased perfusion has compromised viability
    • not for: primary management of wounds, wounds treated with artificial grafts (i.e. bioengineered or allogeniec skin substitutes), empiric treatment, prophylactic maintenance, or preparation of a site to receive a graft
  • Chronic refractory osteomyelitis that is unresponsive to conventional medical and surgical treatment (i.e., prolonged antibiotics therapy preferably directed by appropriate culture and sensitivity information, drainage of the abscesses, immobilization of the affected extremity, and/or surgical debridement with removal of infected bone), when all of the following criteria are met:
    • as an adjunct to continued medical and/or surgical therapy
    • confirmed by imaging findings and bone cultures
  • Osteoradionecrosis, when all of the following criteria are met:
    • as an adjunct to conventional treatment with debridement or resection of nonviable tissue in conjunction with antibiotic therapy
    • history of radiation treatment to the region of the documented injury, terminating at least 6 months prior to onset of signs or symptoms and/or planned surgical intervention at the site
    • adjunct treatment for osteoradionecrosis of the jaw is limited to cases with evidence of overt fracture or bony resorption in a previously irradiated mandible
  • Soft tissue radionecrosis, when all of the following criteria are met:
    • as an adjunct to conventional treatment including debridement or resection of nonviable tissue in conjunction with antibiotic therapy
    • history of radiation treatment to the region of the documented injury, terminating at least 6 months prior to onset of signs or symptoms and/or planned surgical intervention at the site.
  • Cyanide poisoning
  • Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment
  • Diabetic wounds of the lower extremities, when all of the following criteria are met:
    • The individual has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
    • The individual has a wound classified as Wagner grade III or higher; and
    • The individual has failed an adequate course of standard wound therapy.
    • The individual meets the criteria for initiation or continuation of full body HBO:
      • Initiation of full-body HBO therapy to treat diabetic wounds of the lower extremities is considered medically necessary and, therefore, covered as adjunctive therapy when at least 30 consecutive days of standard wound therapy alone has produced no measurable signs of healing. Full-body HBO therapy must be used in addition to standard diabetic wound care measures such as: assessment of vascular status; correction of vascular problems in the affected limb if possible; optimization of nutritional status; optimization of glucose control; debridement by any means to remove devitalized tissue; maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings; appropriate off-loading; and necessary treatment to resolve any infection that might be present; OR
      • Continued treatment of diabetic wounds with full-body HBO therapy is considered medically necessary and, therefore, covered if measurable signs of wound healing are evident after a 30-day period of treatment with both full-body HBO therapy and standard wound therapy. Wounds must be evaluated at least every 30 days during administration of HBO therapy. If no measurable signs of wound healing (defined as specific, documented, clinical signs of healing) are evident after any 30-day period, continued treatment with full-body HBO therapy is considered not medically necessary and, therefore, not covered.

TECHNICAL REQUIREMENTS
HBO therapy for the treatment of the conditions listed above is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • Treatment occurs in a full-body monoplace or multiplace chamber.
  • The individual is provided 100 percent oxygen (systemic).
  • The chamber can reach a pressurization of at least 1.4 ATA.
  • A physician professional provider is onsite who is qualified and appropriately trained in hyperbaric medicine.

When HBO therapy does not meet both the Medical Requirements and the Technical Requirements listed above, it is considered not medically necessary and, therefore, not covered.

TRAINING AND CERTIFICATION REQUIREMENTS
In the inpatient or outpatient hospital setting, the process of determining appropriate provider training and/or certification should be determined by the facility, taking into consideration the potential need for ICU-level services and/or advanced cardiac life support (ACLS) should a complication occur in the delivery of this treatment.

HBO therapy will be covered in the non-hospital-affiliated setting when the facility demonstrates that all of the following criteria are met:
  1. Direct supervision is provided by a physician professional provider certified in Hyperbaric Medicine by the American Board of Emergency Medicine (ABEM), the American Board of Preventive Medicine (ABPM), or the American Osteopathic Conjoint Committee of Undersea and Hyperbaric Medicine (AOCUHM) or other entity adopting UHMS training protocol by completion of a minimum 40-hour training experience in a program approved by the American College of Hyperbaric Medicine or the Undersea and Hyperbaric Medical Society
  2. The supervising provider must be ACLS trained and certified.

PLACE OF SERVICE

This service is only eligible for coverage when performed in the inpatient only setting due to the acute and critical nature of the disease, concomitant conditions, and the need for correlation with other acute, invasive or monitoring services for the following conditions:
  • Gas gangrene
  • Sequelae of acute peripheral ischemia (including reperfusion conditions of arterial embolism and thrombosis, reimplantation and/or crush injuries of the extremities)
  • Necrotizing fasciitis
  • Air embolisms
  • Carbon monoxide/cyanide poisoning

Therefore, HBO therapy is not eligible for coverage for these services in an outpatient or non-acute care setting

NOT MEDICALLY NECESSARY

All other uses for hyperbaric oxygen therapy are considered not medically necessary and, therefore, not covered, such as, but not limited to, the following:
  • Cutaneous, decubitus, and stasis ulcers
  • Chronic peripheral vascular insufficiency
  • Anaerobic septicemia and infection other than clostridial
  • Skin burns (thermal)
  • Senility
  • Myocardial infarction
  • Cardiogenic shock
  • Sickle cell anemia
  • Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency
  • Acute or chronic cerebral vascular insufficiency
  • Hepatic necrosis
  • Aerobic septicemia
  • Nonvascular causes of chronic brain syndrome (Pick’s disease, Alzheimer’s disease, Korsakoff’s disease)
  • Tetanus
  • Systemic aerobic infection
  • Organ transplantation
  • Organ storage
  • Pulmonary emphysema
  • Exceptional blood loss anemia
  • Multiple sclerosis
  • Arthritic diseases
  • Acute cerebral edema

Topical Oxygen

For more information on topical oxygenation, refer to the specific medical policy.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

Documentation includes the hyperbaric procedure (logs) with ascent time, descent time and pressurization level. In addition, there should be a treatment plan identifying timeline and treatment goals.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

The Company reserves the right to review HBO services in consideration with the utilization guidelines listed in Attachment A.

All of the covered conditions, per National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy, represent emergent medical conditions or have occurred secondary to severe systemic illness. Records must demonstrate the involvement of a professional provider skilled in the management of systemic illness, particularly diabetes management, and particularly cardiovascular and neurovascular complications.
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, HBO therapy is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

Description

Hyperbaric oxygen (HBO) therapy involves the inhalation of 100 percent oxygen at an elevated (i.e., greater than sea-level) atmospheric absolute (ATA) of at least 1.4, although the pressure is typically between 2 and 3 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 between 2 and 12 individuals, are pressurized using compressed air; the individuals breathe 100 percent oxygen via mask, head tent, or endotracheal tube. In any of these three settings, the arterial partial pressure of oxygen will approach 1,500 mmHg. Individuals typically spend 1 to 2 hours in the chamber per session as determined by the attending physician. Potential risks for individuals undergoing HBO therapy include pressure-related traumas (e.g., barotraumatic otitis, pneumothorax) and adverse effects (e.g., myopia, seizures) due to oxygen toxicity. Refraction changes are common but usually resolve once treatment is concluded. Hypoglycemia may be induced in diabetic individuals. Rapid ascent from pressure may cause decompression illness or "the bends." Some individuals may experience claustrophobia due to the confined chamber space.

HBO therapy that delivers less than 1.4 ATA or exposes only isolated parts of the body to 100 percent oxygen does not constitute full-body HBO therapy. In addition, treatment that does not require a full-body monoplace or multiplace chamber is considered topical oxygenation.
References

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.29: Hyperbaric oxygen therapy. [CMS Web site]. 04/03/2017. Available at:
https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?ncdid=12&ver=3. Accessed February 05, 2018.

Novitas Solutions, Inc. Local Coverage Determination (LCD).L L35021 Hyperbaric Oxygen (HBO) Therapy. [Novitas, Inc. Medicare Services Web site]. Original: 10/05/2017. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35021&ContrId=334&ver=77&ContrVer=1&CntrctrSelected=334*1&Cntrctr=334&name=&DocType=Active&s=All&bc=AgAAAAIAAAAAAA%3d%3d&. Accessed February 05, 2018.



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)

99183


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)

Report the most appropriate diagnosis code in support of medically necessary criteria as listed in the policy.


HCPCS Level II Code Number(s)

G0277 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval


Revenue Code Number(s)

0413 Respiratory Services-Hyperbaric Oxygen Therapy

Coding and Billing Requirements

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

The number of units reported for G0277 is based upon the time that the patient receives treatment with hyperbaric oxygen. The time spent by the patient under 100% oxygen, descent, air breaks, and ascent are included in calculating the total number of 30-minute intervals to be reported.

An additional unit of service may be reported if the patient is in the chamber receiving hyperbaric oxygen treatment for at least 16 minutes beyond the previous 30-minute period. The following guidelines instruct appropriate reporting of G0277:
  • The first unit reported must be at least 16 minutes in length.
  • The second unit is reported if the session is at least 46 minutes long (first unit = 30 minutes + 16 additional minutes).
  • The third unit is reported if the session is at least 76 minutes long (first and second units = 60 minutes + 16 additional minutes).
  • The fourth unit is reported if the session is at least 106 minutes long (first, second, and third units = 90 minutes + 16 additional minutes).

Physician attendance and supervision of HBO therapy, per session, as represented by Current Procedural Terminology (CPT) code 99183 is eligible to be reported when both the Medical Requirements and the Technical Requirements of full-body HBO therapy, as listed in this policy, are met.

Cross References

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







Policy History


MA07.001a
12/18/2019This policy has been reissued in accordance with the Company's annual review process.
03/28/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on hyperbaric oxygen therapy.
06/07/2017This policy has been reissued in accordance with the Company's annual review process.
12/01/2016The criteria section has been updated to clarify conditional requirements for previously covered criteria.

Added language related to place of service limitation on conditions that are covered only as part of inpatient treatment due to the acuity of the indication.

Added language to REQUIRED DOCUMENTATION section to clarify details needed to support coverage.

Added following Revenue Code
0413 Respiratory Services-Hyperbaric Oxygen Therapy

Utilization Guidelines Attachment reformatted into table format

MA07.001
08/19/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy.
01/01/2015This is a new policy.

On 12/4/2014: The following CPT code has been termed from this policy:

C1300 HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL

The following CPT code has been added to this policy:

G0277 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

The Billing Guidelines section was amended as follows:

BILLING GUIDELINES

Physician or other health care professional attendance and supervision of HBO therapy may be billed using CPT code: 99183, when performed by a professional provider who is on-site.

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

The number of units reported for G0277 is based upon the time that the patient receives treatment with hyperbaric oxygen. The time spent by the patient under 100% oxygen, descent, air breaks, and ascent are included in calculating the total number of 30 minute intervals to be reported.

An additional unit of service may be reported if the patient is in the chamber receiving hyperbaric oxygen treatment for at least 16 minutes beyond the previous 30 minute period. The following guidelines instruct appropriate reporting of G0277:





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