|Subject:||Hyperbaric Oxygen Therapy (Systemic/Topical)|
|Policy #:||MED.00005||Current Effective Date:||01/14/2014|
|Status:||Reviewed||Last Review Date:||11/14/2013|
Systemic hyperbaric oxygen pressurization is a mode of medical treatment in which an individual is entirely enclosed in an air-tight chamber that is pressurized to 1.4 to 3.0 atmospheres absolute (atm abs or ATA) and is breathing 100% oxygen. This increases oxygen levels in systemic circulation. Treatment may be carried out either in a monoplace chamber pressurized with pure oxygen, or in a larger, multiplace chamber pressurized with compressed air, in which case the individual receives pure oxygen by mask, head tent, or endotracheal tube.
Topical hyperbaric oxygen therapy is a technique of delivering 100% oxygen directly to an open moist wound at a pressure slightly higher than atmospheric pressure. It is hypothesized that the high concentrations of oxygen diffuse directly into the wound to increase the local cellular oxygen tension, which in turn promotes wound healing.
Limb specific hyperbaric oxygen therapy is a technique by which a particular limb requiring treatment is placed in a miniature hyperbaric chamber and exposed to hyperbaric oxygen treatments. The rest of the body is not exposed to this treatment.
Note: For information regarding the use of hyperbaric oxygen therapy for the treatment of autism spectrum disorders, please see:
Systemic hyperbaric oxygen pressurization is considered medically necessary in the treatment of any of the following conditions when performed in accordance with Undersea and Hyperbaric Medical Society (UHMS) guidelines:
Not Medically Necessary:
If the wound fails to show measurable signs of healing within 30 days of initiating and at each subsequent 30 day interval of systemic hyperbaric oxygen pressurization, continued therapy is considered not medically necessary.
Investigational and Not Medically Necessary:
Topical hyperbaric oxygen is considered investigational and not medically necessary in all cases.
Limb specific hyperbaric oxygen pressurization is considered investigational and not medically necessary in all cases.
Systemic hyperbaric oxygen pressurization is considered investigational and not medically necessary for all other conditions not previously listed, including but not limited to the treatment of tinnitus.
Systemic Hyperbaric Oxygen
The position regarding systemic hyperbaric oxygen is based on guidelines published by the Undersea and Hyperbaric Medical Society (2008). These guidelines provide recommendations for indications where hyperbaric oxygen therapy has been demonstrated to provide clinical benefits, and where there is adequate data to provide guidance regarding treatment duration, frequency and depth of pressurization.
Undersea and Hyperbaric Medical Society Guidelines:
The Undersea and Hyperbaric Medical Society's (UHMS) 2008 Hyperbaric Oxygen Therapy Committee suggests utilization of systemic hyperbaric oxygen therapy pressurization or "HBOT" guidelines as described below:
In 2012 the American Academy of Neurology and the American Headache Society released guidelines regarding the use of complementary treatments for episodic migraine prevention in adults (Holland, 2012). These guidelines concluded that the data are conflicting or inadequate to support or refute hyperbaric oxygen for migraine prevention.
The use of HBOT has been proposed for a wide range of conditions in addition to those addressed by the UHMS. Most, including cerebral edema, spinal cord injury, and heat trauma have little in the way of clinical data to support HBOT therapy. Further study of the impact of this treatment method for these conditions is warranted.
HBOT treatment for Tinnitus
Hyperbaric oxygen therapy (HBOT) has been proposed as a treatment for tinnitus that frequently accompanies sensorineural hearing loss. In a meta-analysis of the peer-reviewed literature, Bennett and colleagues (2005) evaluated the safety and efficacy of hyperbaric oxygen therapy (HBOT) for the treatment of individuals with idiopathic sudden sensorineural hearing loss (ISSHL) and tinnitus. In a single trial, 50 subjects were assessed for improvement in hearing and tinnitus after treatment with HBOT. Despite reporting improvement in hearing, the significance of any improvement in a subjective rating of tinnitus following HBOT could not be assessed due to poor reporting. The authors concluded that due to the small study population, methodological shortcomings, and the poor reporting, there is a lack of clinical evidence of a "beneficial effect" of HBOT on the chronic presentation of tinnitus. A randomized controlled trial of "high methodological rigor is justified to define those patients (if any) who can be expected to derive most benefit from HBOT" (Bennett, 2005). A recent search of the literature identified only one recent small non-randomized retrospective controlled study involving 48 subjects with ISSHL who received standard care plus HBOT compared to 44 ISSHL subjects who received standard care (Ohno, 2010). No significant differences were noted between groups with regard to mean hearing gain. The authors conclude that "the effectiveness of secondary HBOT for ISSNHL patients in either subacute or chronic phase remains unproven, and thus, the decision to administer HBOT should be made with caution".
In October of 2011 the UHMS added idiopathic sudden sensorineural hearing loss to their list of indications. However, unlike other indications recommended by UHMS, a rationale for this addition has not been made publicly available as of this review and is not on their website (www.UHMS.org). Until a rationale is made available, we cannot fully evaluate this recommendation.
In 2012, the American Academy of Otolaryngology-Head and Neck Surgery published their clinical practice guideline for sudden hearing loss. In this document they state; "The panel offered as options that clinicians may offer (1) corticosteroids as initial therapy to patients with ISSNHL [Idiopathic Sudden Sensoneural Hearing Loss] and (2) hyperbaric oxygen therapy within 3 months of diagnosis of ISSNHL." This recommendation is based on aggregate evidence quality "Grade B, systematic review of RCTs with methodological limitations". It is concluded that the evidence supporting the use of HBOT for the treatment of ISSHL is currently insufficient to draw reasonable conclusions about the efficacy of this service at this time.
Topical and Limb Specific Hyperbaric Oxygen Therapy
Due to their different methods of delivery, topical (including limb specific treatment) and systemic HBOT are distinct technologies such that the outcomes associated with systemic HBOT cannot be extrapolated to topical therapy. Topical HBOT has been primarily investigated as a treatment of chronic wounds, but other conditions have also been proposed as possible indications. There is currently insufficient published data from controlled trials to permit conclusions regarding topical HBOT. Additionally, evidence in the form of data from in vitro studies of limb specific HBOT have failed to demonstrate that this treatment method increases tissue oxygen tension beyond the superficial dermis, a key factor in the efficacy of HBOT. At this time the use of topic and limb specific HBOT are not supported by the available scientific evidence.
Systemic Hyperbaric Oxygen Therapy
Systemic hyperbaric oxygen therapy (HBOT) involves the inhalation of pure oxygen gas while enclosed in a high-pressure chamber (defined as pressure greater than standard atmospheric pressure). The therapy works by supersaturating the blood tissues with oxygen via increased atmospheric pressure as well as increased oxygen concentrations. Studies have demonstrated that this therapy increases the available oxygen to the body by 10 to 20 times normal levels. Treatment may be carried out in either a monoplace chamber pressurized with pure oxygen or in a larger, multiplace chamber pressurized with compressed air, in which case the individual receives pure oxygen by mask, head tent, or endotracheal tube. The number and duration of treatment sessions and the atmospheric pressure during treatment varies depending on the specific condition being treated, the severity of the condition, and the procedures developed by individual hospitals and clinics. These individual procedures vary widely and have made the evaluation of the efficacy of hyperbaric oxygen therapy difficult. However, the medical specialty society which represents the physicians who specialize in this type of medical treatment, called the Undersea and Hyperbaric Medical Society (UHMS), created treatment recommendations for a wide variety of conditions for which HBOT has been proven to provide significant benefits.
Topical Hyperbaric Oxygen Therapy
Topical HBOT involves the delivery of pure oxygen directly to an open, moist wound at a pressure slightly higher than atmospheric pressure. Limb specific HBOT involves the use of a plastic container into which the limb to be treated is inserted and then sealed with pliable gaskets. The limb is then subjected to increased pressure and oxygen concentrations. Much of the research on these forms of has focused on chronic wounds arising in individuals with diabetes– specifically foot wounds responsible for significant mortality and morbidity.
Anemia: A reduction in the number of circulating red blood cells or in the total hemoglobin content of the cells.
Atmospheres absolute (ATA): The combination (or the sum) of the atmospheric pressure and the hydrostatic pressure is called atmospheres absolute (ATA). In other words, the ATA or atmospheres absolute is the total weight of the water and air above us.
Carbon monoxide poisoning: Toxicity that results from inhalation of small amounts of carbon monoxide (a poisonous gas) over a long period of time or from large amounts inhaled for a short time, which leads to decreased oxygen delivery to the body.
Chronic: Of a long duration; a disease that persists or progresses over time.
Compartmental syndrome: Any condition in which a structure such as a nerve or tendon is being constricted in a space and is no longer able to move freely in the compartment.
Decompression sickness: A condition that develops in divers subjected to rapid reduction of air pressure after coming to the surface following exposure to compressed air.
Gangrene: The death of tissue or bone, usually resulting from a deficient or absent blood supply.
Gas embolism: Obstruction of a blood vessel by a gas bubble.
Ischemia: A local and temporary deficiency of blood supply due to an obstruction of the circulation.
Limb specific hyperbaric oxygen: A therapy that involves sealing an individual's leg or arm into an airtight container and exposing that limb to pure oxygen greater than one atmosphere of pressure.
Mycosis: Any condition caused by a fungus.
Necrosis: A condition where cells or tissues are dead or dying.
Osteomyelitis: Inflammation of the bone due to infection.
Osteoradionecrosis: Death of bone following irradiation.
Prophylactic: Any agent or treatment that contributes to the prevention of infection or disease.
Pyoderma gangrenosum: A condition of the skin leading to open ulcers.Systemic hyperbaric oxygen: A therapy that involves sealing an individual inside a room or container, then exposing the individual to pure oxygen at greater than one atmosphere of pressure.
Thermal: Related to heat.
Tinnitus: A condition where an individual has the perception of sound in their head when no outside sound is present. Typically referred to as "ringing in the ears" or "head noise," but other forms of sound have been described such as hissing, roaring, pulsing, whooshing, chirping, whistling and clicking.
Topical hyperbaric oxygen: A therapy that involves sealing skin wounds under a plastic cover and then exposing the wound to pure oxygen at greater than one atmosphere of pressure; an alternate form of this therapy involves the application of a mist of water droplets to the wound that are saturated with dissolved oxygen.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
When services are Medically Necessary:
|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|
|ICD-9 Procedure||[For dates of service prior to 10/01/2014]|
|93.59||Other immobilization, pressure and attention to wound (hyperbaric oxygenation of wound)|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2014]|
|111.0-111.9||Dermatomycosis, other and unspecified|
|117.7||Zygomycosis (Phycomycosis, Mucormycosis, Conidiobolus infection)|
|117.9||Other and unspecified mycoses|
|285.1||Acute posthemorrhagic anemia|
|362.31||Central retinal artery occlusion|
|443.89||Other specified peripheral vascular diseases|
|443.9||Peripheral vascular disease, unspecified (peripheral arterial insufficiency)|
|444.21||Arterial embolism, upper extremity|
|444.22||Arterial embolism, lower extremity|
|444.81||Arterial embolism, iliac artery|
|459.9||Unspecified circulatory system disorder|
|526.4||Inflammatory conditions of jaw, osteomyelitis acute, chronic, suppurative|
|526.89||Osteoradionecrosis of jaw|
|686.00-686.9||Other local infections of skin and subcutaneous tissue|
|707.00-707.19||Pressure ulcers, ulcer of lower limbs except pressure ulcers|
|707.20-707.25||Pressure ulcer stages|
|707.8-707.9||Chronic ulcer of other and unspecified sites|
|728.9||Unspecified disorder of muscle, ligament, and fascia|
|729.71-729.79||Nontraumatic compartment syndrome|
|902.53||Injury to iliac artery|
|903.01||Injury to axillary artery|
|903.1-903.9||Injury to blood vessels of upper extremity|
|904.0||Injury to common femoral artery|
|904.1||Injury to superficial femoral artery|
|904.41||Injury to popliteal artery|
|904.51||Injury to anterior tibial artery|
|904.53||Injury to posterior tibial artery|
|904.6-904.9||Injury to other blood vessels of lower extremity|
|906.0-906.1||Late effect of open wound|
|906.4||Late effect of crushing|
|909.2||Late effect of radiation|
|941.20-941.59||Burns of face, head and neck, second and third degree|
|942.20-942.59||Burns of trunk, second and third degree|
|943.20-943.59||Burns of upper limb second and third degree|
|944.20-944.58||Burns of wrist and hand, second and third degree|
|945.20-945.59||Burns of lower limb, second and third degree|
|946.2-946.5||Burns of multiple specified sites, second and third degree|
|948.00-948.99||Burns classified according to extent of body surface involved, second and third degree|
|949.2-949.5||Burn, unspecified second and third degree|
|958.0||Air embolism, early complication of trauma|
|958.8||Other early complications of trauma|
|958.90-958.99||Traumatic compartment syndrome|
|986||Toxic effect of carbon monoxide|
|987.7||Toxic effect of hydrocyanic acid gas|
|989.0||Toxic effect of hydrocyanic acid and cyanides|
|990||Effects of radiation, unspecified|
|993.3||Caisson disease (decompression sickness, bends)|
|996.52||Mechanical complication due to graft of other tissue, not elsewhere classified (skin graft failure)|
|996.69||Infection and inflammatory reaction due to other internal prosthetic device, implant, and graft|
|996.79||Other complications due to other internal prosthetic device, implant, and graft|
|998.83||Non-healing surgical wound|
|999.1||Air embolism, complication of medical care|
|ICD-10 Procedure||[For dates of service on or after10/01/2014]|
|5A05121||Extracorporeal hyperbaric oxygenation, intermittent|
|5A05221||Extracorporeal hyperbaric oxygenation, continuous|
|ICD-10 Diagnosis||[For dates of service on or after10/01/2014]|
|B36.0-B36.9||Other superficial mycoses|
|B48.0-B48.8||Other mycoses, not elsewhere classified|
|D62||Acute posthemorrhagic anemia|
|E13.00-E13.9||Other specified diabetes mellitus|
|G06.0||Intracranial abscess and granuloma|
|H34.10-H34.13||Central retinal artery occlusion|
|I73.89||Other specified peripheral vascular diseases|
|I73.9||Peripheral vascular disease, unspecified|
|I74.2-I74.9||Embolism and thrombosis of arteries (upper/lower extremities, iliac artery)|
|I96||Gangrene, not elsewhere classified|
|I99.9||Unspecified disorder of circulatory system|
|L08.0-L08.9||Other local infections of skin and subcutaneous tissue|
|L97.101-L97.929||Non-pressure chronic ulcer of lower limb, not elsewhere classified|
|L98.411-L98.499||Non-pressure chronic ulcer of skin, not elsewhere classified|
|M27.2||Inflammatory conditions of jaws|
|M79.9||Soft tissue disorder, unspecified|
|M79.A11-M79.A9||Nontraumatic compartment syndrome|
|S01.00XS-S01.95XS||Open wound of head [range with 7th character S]|
|S07.0XXA-S07.9XXS||Crushing injury of head|
|S11.011S-S11.95XS||Open wound of neck [range with 7th character S]|
|S17.0XXA-S17.9XXS||Crushing injury of neck|
|S21.001S-S21.95XS||Open wound of thorax [range with 7th character S]|
|S31.000S-S31.839S||Open wound of abdomen, lower back, pelvis and external genitals [range with 7th character S]|
|S38.001A-S38.1XXS||Crushing injury of abdomen, lower back, pelvis and external genitals|
|S41.001S-S41.159S||Open wound of shoulder and upper arm [range with 7th character S]|
|S45.001A-S45.099S||Injury of axillary artery|
|S45.801A-S45.999S||Unspecified injury of other blood vessels at shoulder and upper arm level|
|S47.1XXA-S47.9XXS||Crushing injury of shoulder and upper arm|
|S51.001S-S51.859S||Open wound of elbow and forearm [range with 7th character S]|
|T20.20XA-T20.29XS||Burn of second degree of head, face, and neck|
|T20.30XA-T20.39XS||Burn of third degree of head, face, and neck|
|T21.20XA-T21.29XS||Burn of second degree of trunk|
|T21.30XA-T21.39XS||Burn of third degree of trunk|
|T22.20XA-T22.299S||Burn of second degree of shoulder and upper limb, except wrist and hand|
|T22.30XA-T22.399S||Burn of third degree of shoulder and upper limb, expect wrist and hand|
|T23.201A-T23.299S||Burn of second degree of wrist and hand|
|T23.301A-T23.399S||Burn of third degree of wrist and hand|
|T24.201A-T24.299S||Burn of second degree of lower limb, except ankle and foot|
|T24.301A-T24.399S||Burn of third degree of lower limb, except ankle and foot|
|T25.211A-T25.299S||Burn of second degree of ankle and foot|
|T25.311A-T25.399S||Burn of third degree of ankle and foot|
|T31.0-T31.99||Burns classified according to extent of body surface involved|
|T57.3X1A-T57.3X4S||Toxic effect of hydrogen cyanide|
|T58.01XA-T58.94XS||Toxic effect of carbon monoxide|
|T65.0X1A-T65.0X4S||Toxic effect of cyanides|
|T70.3XXA-T70.3XXS||Caisson disease [decompression sickness]|
|T79.0XXA-T79.0XXS||Air embolism (traumatic)|
|T79.A0XA-T79.A0XS||Compartment syndrome, unspecified|
|T79.A11A-T79.A9XS||Traumatic compartment syndrome|
|T86.820-T86.829||Complications of skin graft (allograft)(autograft)|
When services are Not Medically Necessary:
For the procedure codes listed above, when the situation listed in the Position Statement section as not medically necessary applies.
When services are Investigational and Not Medically Necessary:
For the procedure codes listed above, for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.
When services are also Investigational and Not Medically Necessary:
|A4575||Topical hyperbaric oxygen chamber, disposable|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2014]|
|ICD-10 Diagnosis||[For dates of service on or after10/01/2014]|
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Web Sites for Additional Information|
Extreme Chamber Therapy
Extremity Oxygen Therapy
Osteomyelitis, Acute and Chronic
|Reviewed||11/14/2013||Medical Policy & Technology Assessment Committee (MPTAC) review. No change to the position statement. Updated Rationale and Reference sections.|
|Reviewed||11/08/2012||MPTAC review. No change to the position statement. Updated Rationale and Reference sections. Updated Coding section with 01/01/2013 CPT descriptor change.|
|Reviewed||11/17/2011||MPTAC review. No change to the position statement. Updated reference section.|
|Revised||11/18/2010||MPTAC review. Moved HBOT treatment of tinnitus to investigational and not medically necessary section from MED.00073 Treatment of Tinnitus which was archived. Updated Rationale and Reference sections.|
|Reviewed||02/25/2010||MPTAC review. No change to position statement. Updated Reference section.|
|10/01/2009||Updated Coding section with 10/01/2009 ICD-9 changes.|
|Revised||02/26/2009||MPTAC review. Clarified use in chronic wounds to require reassessment at each subsequent 30 day interval. Added central retina artery occlusion (CRAO) as a medically necessary indication. Added central retina artery occlusion (CRAO) as a medically necessary indication. Changed "profound" anemia to "severe" anemia in medically necessary section. Deleted "acute" osteomyelitis and cerebral edema from the medically necessary section. Revised medically necessary statement regarding radiation necrosis to read "delayed radiation injury". Deleted list of I/E and NMN indications, leaving it to read I/E and NMN "for all indications". Updated Rationale, Background, Coding and Reference sections.|
|Revised||08/28/2008||MPTAC review. Added radiation cystitis as medically necessary when used as an adjuvant therapy. Added tinnitus to investigational and not medically necessary section. Deleted "intracranial abscess" from investigational and not medically necessary section. Revised Rationale section. Updated Coding section with 10/01/2008 ICD-9 changes.|
|Reviewed||05/15/2008||MPTAC review. No change to position statement. Updated Coding and Reference sections.|
|02/21/2008||The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.|
|Reviewed||05/17/2007||MPTAC review. No change to position statement. Updated Coding and Reference sections.|
|Revised||06/08/2006||MPTAC review. Moved radiation cystitis from Investigational and Not Medically Necessary to Medically Necessary. Updated Coding and Reference sections.|
|11/22/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||07/14/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Last Review Date||Document Number|
|04/28/2005||MED.00005||Hyperbaric Oxygen Therapy (Systemic/Topical)|
|WellPoint Health Networks, Inc.||04/28/2005||2.01.01||Hyperbaric Oxygen Therapy: Systemic|
|09/23/2004||2.02.01||Oxygen Therapy (Low Pressure) for Wound Care|