Hyperbaric and Topical Oxygen Wound Therapies HYPERBARIC AND TOPICAL OXYGEN WOUND THERAPIES HS-032. Policy Number: HS-032

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1 Easy Choice Health Plan, Inc. Harmony Health Plan of Illinois, Inc. Missouri Care, Inc. Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare Health Insurance of Illinois, Inc. WellCare Health Plans of New Jersey, Inc. WellCare Health Insurance of Arizona, Inc. WellCare of Florida, Inc. WellCare of Connecticut, Inc. WellCare of Georgia, Inc. WellCare of Kentucky, Inc. WellCare of Louisiana, Inc. WellCare of New York, Inc. WellCare of Ohio, Inc. WellCare of South Carolina, Inc. WellCare of Texas, Inc. WellCare Prescription Insurance, Inc. Windsor Health Plan Windsor Rx Medicare Prescription Drug Plan Hyperbaric and Topical Oxygen Wound Therapies Policy Number: Original Effective Date: 7/17/2008 Revised Date(s): 8/13/2009; 8/20/2010; 8/2/2011; 8/2/2012; 8/1/2013; 7/10/2014 APPLICATION STATEMENT The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.

2 DISCLAIMER The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member s benefit plan may contain specific exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member s Benefit Plan always supersedes the information contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Note: The lines of business (LOB) are subject to change without notice; consult for list of current LOBs. BACKGROUND Hyperbaric Oxygen (HBO) Therapy is a medical treatment in which the patient is entirely enclosed in a pressure chamber breathing 100% oxygen (O 2 ) at a pressure greater than one atmosphere (atm). Either a mono-place chamber pressurized with pure O 2 or a larger multi-place chamber pressurized with compressed air where the patient receives pure O 2 by mask, head tent, or endotracheal tube may be used. A hyperbaric oxygen chamber (whether single or multiple chamber [i.e., created to hold several people]) is a device intended to increase the environmental oxygen pressure to promote the movement of oxygen from the environment to a patient s tissues by means of pressurization that is greater than atmospheric pressure. Complications from this therapy can be minimized if pressures within the chamber remain below three times the normal atmospheric pressure and sessions last no longer than two hours. The safety and efficacy of HBO therapy has been demonstrated for numerous conditions in evidence-based, peerreviewed journals, consensus guidelines and numerous textbooks. HBO therapy is the standard of care in the primary treatment of acute carbon monoxide poisoning, arterial gas embolism, and decompression sickness. Through the forced exchange of oxygen at the plasma levels, tissue function can be sustained. Wagner Scale Grade 0: No ulcer in a high risk foot. Grade 1: Superficial ulcer involving the full skin thickness but not underlying tissues. Grade 2: Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation. Grade 3: Deep ulcer with cellulitis or abscess formation, often with osteomyelitis. Grade 4: Localized gangrene. Grade 5: Extensive gangrene involving the whole foot. Topical Oxygen Therapy Topical oxygen therapy involves the application of gaseous oxygen to a cutaneous wound. To treat an affected foot, a boot-shaped plastic bag with a gas inlet is attached to the leg with adhesive tape, then the bag is pumped full of pure oxygen. Cutaneous lesions that are not located on hands or feet can be treated with a plastic sheet that is sealed around the edges and then filled with oxygen. Regardless of the location of the lesion, oxygen is pumped into the bag or plastic sheet until the pressure reaches to 1.04 atmospheres, since the elevated pressure is believed to facilitate diffusion of oxygen into the wound. A pressurized bag sealed around an extremity can exert a tourniquet-like effect; during treatment, some practitioners continuously cycle bag pressure from full pressure to no pressure and back to full every 40 seconds to limit this effect (Hayes, 2002). Clinical Coverage Guideline page 2

3 POSITION STATEMENT Hyperbaric Oxygen Therapy Applicable To: Medicaid All Markets Medicare All Markets Hyperbaric oxygen (HBO) therapy is considered medically necessary for the following indications: Acute carbon monoxide intoxication Decompression illness Gas embolism Gas gangrene Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened Crush injuries and suturing of severed limbs. As in indication #5, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened Necrotizing infections (necrotizing fasciitis) Acute peripheral arterial insufficiency Preparation and preservation of compromised skin grafts (not for primary management of wounds) Refractory osteomyelitis, unresponsive to conventional medical and surgical management Osteoradionecrosis as an adjunct to conventional treatment Soft tissue radionecrosis as an adjunct to conventional treatment Cyanide poisoning Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antifungal medication and surgical treatment Diabetic with wounds of the lower extremities in patients who meet the following criteria: o Patient has a wound classified as Wagner grade III or higher (see scale below); and o Patient has failed an adequate course of standard wound therapy. The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds includes: assessment of a patient s vascular status and correction of any 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. Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. Hyperbaric oxygen therapy may be considered experimental and investigational and NOT a covered benefit for the following indications: Cutaneous, decubitus, and stasis ulcers Chronic peripheral vascular insufficiency Anaerobic septicemia and infection other than clostridial Skin burns (thermal) Senility Clinical Coverage Guideline page 3

4 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 Autism Topical Oxygen Wound Therapy Applicable To: Medicaid New York Topical Oxygen Wound Therapy is considered medically necessary and a covered benefit for New York Medicaid ONLY when criteria 1 and ANY of criteria 2-6 of the New York Medicaid TOWT guidelines are met: 1. A complete wound therapy program as applicable, depending on the type of wound, has been attempted prior to application of TOWT, including: a. Documentation in the patient's medical record of evaluation, care, compliance and wound measurements by the treating physician, AND, b. Application of dressings to maintain a moist wound environment, AND, c. Debridement of necrotic tissue if present, AND, d. Evaluation of and provision for adequate nutritional status. 2. Stage IV pressure ulcers: a. The patient has been appropriately turned and positioned, AND, b. The patient has used a support surface for pressure ulcers on the posterior trunk or pelvis (not required if the ulcer is not on the trunk or pelvis), AND, c. The patient's moisture and incontinence have been appropriately managed. OR, 3. Neuropathic (for example, diabetic) ulcers: a. The patient has been on a comprehensive diabetic management program, AND, b. Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities, OR, 4. Venous insufficiency ulcers: Clinical Coverage Guideline page 4

5 OR, a. Compression bandages and/or garments have been consistently applied, AND, b. Leg elevation and ambulation have been encouraged. 5. For non-healing surgically created or traumatic wounds, documentation of medical necessity for accelerated formation of granulated tissue as a result of which cannot be achieved by other topical wound treatments, OR, 6. A chronic (being present for at least 30 days) ulcer of mixed etiology. An initial prior authorization will be granted for a maximum of 16 days in a 28 day period, as treatment is 4 days on, 3 days off. CODING Hyperbaric Oxygen Therapy Applicable To: Medicaid All Markets Medicare All Markets Covered CPT Codes Physician attendance and supervision of hyperbaric oxygen therapy, per session Covered HCPCS Level II Code C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval Non Covered HCPCS Level II Code A4575 Topical hyperbaric oxygen chamber, disposable Covered ICD-9 Procedure Codes Hyperbaric Oxygenation of Wound Hyperbaric Oxygenation DRAFT 2013 ICD-10-PCS Codes 5A05121 Extracorporeal Asst/Performance Physiological Systems, Assistance, Circulatory, Intermittent, Oxygen, Hyperbaric 5A05221 Extracorporeal Asst/Performance Physiological Systems, Assistance, Circulatory, Continuous, Oxygen, Hyperbaric Covered ICD-9 Diagnosis Codes Actinomycotic infections (See specific indication above.) Gas gangrene [Clostridial myositis and myonecrosis] Diabetes with peripheral circulatory disorders [non-healing infected deep ulcerations (reaching tendons or bone) of the lower extremity unresponsive to at least 1 month of meticulous wound care, including aggressive debridement, maximal antibiotic therapy, tight glycemic control, and appropriate treatment of arterial insufficiency, including revascularization if necessary] Diabetes with other specified manifestations [non-healing infected deep ulcerations (reaching tendons or bone) of the lower extremity unresponsive to at least 1 month of meticulous wound care, including aggressive debridement, maximal antibiotic therapy, tight glycemic control, and appropriate treatment of arterial insufficiency, including revascularization if necessary] Atherosclerosis of native arteries and bypass graft of extremities [non-healing infected deep Clinical Coverage Guideline page 5

6 ulcerations (reaching tendons or bone) of the lower extremity unresponsive to at least 1 month of meticulous wound care, including aggressive debridement, maximal antibiotic therapy, tight glycemic control, and appropriate treatment of arterial insufficiency, including revascularization if necessary] Other peripheral vascular disease [acute peripheral arterial insufficiency] Other specified peripheral vascular diseases [acute peripheral arterial insufficiency] Arterial embolism of the extremities [acute peripheral arterial insufficiency] Arterial embolism and thrombosis of the iliac artery [acute peripheral arterial insufficiency] Varicose veins of lower extremities with ulcer [non-healing infected deep ulcerations (reaching tendons or bone) of the lower extremity unresponsive to at least 1 month of meticulous wound care, including aggressive debridement, maximal antibiotic therapy, tight glycemic control, and appropriate treatment of arterial insufficiency, including revascularization if necessary] Varicose veins of lower extremities with ulcer and inflammation [non-healing infected deep ulcerations (reaching tendons or bone) of the lower extremity unresponsive to at least 1 month of meticulous wound care, including aggressive debridement, maximal antibiotic therapy, tight glycemic control, and appropriate treatment of arterial insufficiency, including revascularization if necessary] Inflammatory conditions of the jaws [radiation necrosis of jaw] Other specified diseases of jaw [prophylactic pre- and post-treatment for members undergoing dental surgery of a radiated jaw] [osteoradionecrosis] Ulcer of lower limbs, except pressure ulcer Ulcer of lower limbs, except pressure ulcer Necrotizing fasciitis Chronic osteomyelitis [unresponsive to conventional medical and surgical management] Other ascepticnecrosis of bone; i.e. osteoradionecrosis Gangrene Traumatic amputation thumb, finger(s), arm and hand [when loss of function or life is threatened and HBOT is used in combination with standard therapy] Traumatic amputation toe(s), foot, leg(s) [when loss of function or life is threatened and HBOT is used in combination with standard therapy] Injury to the iliac artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy] Injury to axillary artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy] Injury to palmar artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy] Injury to other specified blood vessels of upper extremity [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy] Injury to common femoral artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy] Injury to superficial femoral artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy] Injury to popliteal artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy] Injury to anterior tibial artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy] Injury to posterior tibial artery [acute peripheral ischemia when loss of function, limb, or life is Threatened and HBOT is used in combination with standard therapy] Injury to other specified blood vessels of lower extremity [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy] Crush injuries [when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy] Clinical Coverage Guideline page 6

7 958.0 Air embolism [acute] Compartment syndrome 986 Toxic effect of carbon monoxide [acute] Toxic effect of hydrocyanic acid gas [with co-existing carbon monoxide poisoning] Toxic effect of hydrocyanic acid and cyanides [with co-existing carbon monoxide poisoning] 990 Effects of radiation, unspecified [radiation necrosis (osteoradionecrosis, myoradionecrosis, brain radionecrosis, and other soft tissue radiation necrosis) or proctitis] [not covered for radiation induced cystitis, myelitis, enteritis, or optic nerve injury] Caisson disease [decompression illness] Mechanical complications due to graft of other tissue, not elsewhere classified [compromised skin grafts and flaps] Mechanical complications due to artificial skin graft and decellularized allodermis [compromised skin grafts and flaps] Infection and inflammatory reaction due to other internal prosthetic device, implant, and graft [compromised skin grafts and flaps] Other complications due to other internal prosthetic device, implant, and graft [compromised skin grafts and flaps] Complications of reattached extremity or body part Other postoperative infection [non-healing infected deep ulcerations (reaching tendons or bone) of the lower extremity unresponsive to at least 1 month of meticulous wound care, including aggressive debridement, maximal antibiotic therapy, tight glycemic control, and appropriate treatment of arterial insufficiency, including revascularization if necessary] Non-healing surgical wound [non-healing infected deep ulcerations (reaching tendons or bone) of the lower extremity unresponsive to at least 1 month of meticulous wound care, including aggressive debridement, maximal antibiotic therapy, tight glycemic control, and appropriate treatment of arterial insufficiency, including revascularization if necessary] Air embolism Covered Draft 2013 ICD-10-CM Diagnosis Codes A48.0 Gas gangrene A42.89 Other forms of actinomycosis E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E Diabetes mellitus due to underlying condition with foot ulcer E Diabetes mellitus due to underlying condition with other skin ulcer E09.52 Drug or Chemical induced Diabetes mellitus with diabetic peripheral angiopathy with gangrene E Drug or chemical induced diabetes mellitus with foot ulcer E Drug or chemical induced diabetes mellitus with other skin ulcer E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E Type 1 diabetes mellitus with foot ulcer E Type 1 diabetes mellitus with other skin ulcer E11.52 Type 2 Diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 Diabetes mellitus with other circulatory complications E Type 2 Diabetes mellitus with foot ulcer E Type 2 Diabetes mellitus with other skin ulcer E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.59 Other specified diabetes mellitus with other circulatory complications E Other specified diabetes mellitus with foot ulcer E Other specified diabetes mellitus with other skin ulcer I I Atherosclerosis of native arteries of right leg with ulceration I I Atherosclerosis of native arteries of left leg with ulceration I I Atherosclerosis of native arteries of extremities with gangrene Clinical Coverage Guideline page 7

8 I I Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration I I70.35 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration I I Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene I I Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration I I70.45 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration I I Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene I I Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration I I70.55 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration I I Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene I I Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration I I70.65 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration I I Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene I I Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration I I70.75 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration I I Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene I73.01 Raynaud s syndrome with gangrene I73.9 Peripheral vascular disease, unspecified I74.2 Embolism and thrombosis of arteries of the upper extremities I74.3 Embolism and thrombosis of arteries of the lower extremities I74.5 Embolism and thrombosis of iliac artery I77.2 Rupture of artery; erosion, fistula, ulcer I79.8 Other disorders of arteries, arterioles and capillaries in disease classified elsewhere I I Varicose veins of right lower extremity with both ulcer and inflammation I I Varicose veins of left lower extremity with both ulcer and inflammation K68.11 Other postoperative infection L L Pressure ulcer of elbow L L Pressure ulcer of back L L Pressure ulcer of sacral region L L Pressure ulcer of unspecified hip L L Pressure ulcer of unspecified buttock L L89.44 Pressure ulcer of contiguous site of back, buttock, and hip L L Pressure ulcer of unspecified ankle L L Pressure ulcer of unspecified heel L L Pressure ulcer of head L L Pressure ulcer of other site L L Non-pressure chronic ulcer of other part of foot L L Non-pressure chronic ulcer of unspecified part of lower leg L L Non-pressure chronic ulcer of buttock L L Non-pressure chronic ulcer of back L L Non-pressure chronic ulcer of skin of other sites M27.2 Inflammatory conditions of jaws M27.8 Other specified disease of jaws M72.6 Necrotizing fasciitis M M86.69 Chronic osteomyelitis M M87.9 Osteonecrosis S S04.62 Injury of acoustic nerve S S47.9 Crushing injury of shoulder and upper arm S S77.22 Crushing Injury of hip and thigh S S87.82 Crushing injury of lower leg S S97.82 Crushing injury of ankle and foot (ankle toe, foot) S S Injury of unspecified iliac artery, S S Injury of axillary artery Clinical Coverage Guideline page 8

9 S S Injury of brachial artery S S Injury of axillary or brachial vein S S Injury of superficial vein at shoulder and upper arm level S S Injury of other blood vessels at shoulder and upper arm level S S Injury of ulnar artery at forearm level S S Injury of radial artery at forearm level S S Injury of vein at forearm level S S Injury of ulnar artery at wrist and hand level S S Injury of radial artery at wrist and hand level S S Injury of superficial palmar arch S S Injury of other blood vessels at wrist and hand level S S Traumatic amputation of wrist, hand and fingers S S Injury of femoral artery S S Injury of other blood vessels at hip and thigh level S S Injury of popliteal artery S S Injury of tibial artery S S Injury of anterior tibial artery S S Injury of posterior tibial artery S S Injury of dorsal artery of foot S S Injury of plantar artery of foot S S Traumatic amputation of foot and toes S S Traumatic amputation of midfoot and foot T57.3X1A -T57.3X4A Toxic effect of hydrogen cyanide T58.01XA -T58.94XA Toxic effect of carbon monoxide T65.0X1A -T65.0X4A Toxic effect of cyanides T66.XXXA Radiation sickness, unspecified T70.3XXA Effects of air pressure and water pressure T79.0XXA Air embolism (traumatic) T79.A11 - T79.9 Traumatic compartment syndrome T81.4XXA Infection following a procedure, initial encounter T81.89XA Other complications of procedures, not elsewhere classified, initial encounter T85.693A Other mechanical complication of artificial skin graft & decellularized allodermis, initial encounter T85.79XA Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts T85.81XA -T85.89XA Other specified complications of internal prosthetic devices, implants and grafts, NEC T T Complications of skin graft (allograft) (autograft); rejection; failure Topical Oxygen Wound Therapy Applicable To: Medicaid New York CPT Codes Physician attendance and supervision of hyberbaric oxygen therapy, per session C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval Covered HCPCS Codes - when criteria 1 and any of criteria 2-6 noted above are met: A4575 Topical hyperbaric oxygen chamber, disposable E0446 Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories Covered ICD-9-CM Procedure Codes Oxygenation of wound (hyperbaric) Clinical Coverage Guideline page 9

10 Covered ICD-9-CM Diagnosis Codes The following diagnosis codes are covered when criteria 1 and any of criteria 2-6 noted above are met Secondary diabetes mellitus with peripheral circulatory disorders Secondary diabetes mellitus with associated ulceration Diabetes with peripheral circulatory disorders Diabetes with associated ulceration Peripheral Angiopathy related to Diabetes Venous Stasis Ulcer, Venous (peripheral) insufficiency Unspecified Chronic Ulcer of Skin Ulcer of lower limbs, except pressure ulcer Pressure ulcer stages Open wound of cheek, complicated Open wound of forehead, complicated Open wound of jaw, complicated Open wound of face, other and multiple sites, complicated Open wound of other and unspecified parts of neck, complicated Open wound of chest (wall), complicated Open wound of back, complicated Open wound of buttock, complicated Open wound of breast, complicated Open wound of abdominal wall, anterior, complicated Open wound of abdominal wall, lateral, complicated Open wound of other and unspecified parts of trunk, complicated Open wound(s) (multiple) of unspecified site(s), complicated Open wound of shoulder region, complicated Open wound of scapular region, complicated Open wound of axillary region, complicated Open wound of upper arm, complicated Open wound of multiple sites of shoulder and upper arm, complicated Open wound of forearm, complicated Open wound of elbow, complicated Open wound of wrist, complicated Open wound of hand except finger(s) alone, complicated Open wound of finger(s), complicated Multiple and unspecified open wound of upper limb, complicated Traumatic amputation of thumb (complete) (partial), complicated Traumatic amputation of other finger(s) (complete) (partial), complicated Traumatic amputation of arm and hand (complete) (partial), unilateral, below elbow, complicated Traumatic amputation of arm and hand (complete) (partial), unilateral, at or above elbow, complicated Traumatic amputation of arm and hand (complete) (partial), unilateral, level not specified, complicated Traumatic amputation of arm and hand (complete) (partial), bilateral (any level), complicated Open wound of hip and thigh, complicated Open wound of knee, leg (except thigh), and ankle, complicated Open wound of foot except toe(s) alone, complicated Open wound of toe(s), complicated Multiple and unspecified open wound of lower limb, complicated Traumatic amputation of toe(s) (complete) (partial), complicated Traumatic amputation of foot (complete) (partial), unilateral, complicated Clinical Coverage Guideline page 10

11 896.3 Traumatic amputation of foot (complete) (partial), bilateral, complicated Traumatic amputation of foot (complete) (partial), bilateral, complicated Traumatic amputation of leg(s) (complete) (partial), unilateral, at or above knee, complicated Traumatic amputation of leg(s) (complete) (partial), unilateral, level not specified, complicated Traumatic amputation of leg(s) (complete) (partial), bilateral (any level), complicated Post-traumatic Wound Infection Non-Healing Surgical Wound ICD-10-Diagnosis Codes E E08.53 Diabetes mellitus due to underlying condition with circulatory complications E E09.59 Drug or chemical induced diabetes mellitus with circulatory complications E E Drug or chemical induced diabetes mellitus with skin complications E E10.59 Type 1 diabetes mellitus with circulatory complications E E Type 1 diabetes mellitus with skin complications E E11.59 Type 2 diabetes mellitus with circulatory complications E E Type 2 diabetes mellitus with skin complications E E13.59 Other specified diabetes mellitus with circulatory complications E E Other specified diabetes mellitus with skin complications I79.8 Other disorders of arteries, arterioles and capillaries in diseases classified elsewhere I87.2 Venous insufficiency (chronic)(peripheral) L L Pressure ulcer of unspecified elbow L L Pressure ulcer of right elbow L L Pressure ulcer of left elbow L L Pressure ulcer of back L L Pressure ulcer of right upper back L L Pressure ulcer of left upper back L L Pressure ulcer of right lower back L L Pressure ulcer of left lower back L L Pressure ulcer of sacral region L L Pressure ulcer of hip L L Pressure ulcer of right hip L L Pressure ulcer of left hip L L Pressure ulcer of buttock L L Pressure ulcer of right buttock L L Pressure ulcer of left buttock L L89.44 Pressure ulcer of contiguous site of back buttock and hip L L Pressure ulcer of ankle L L Pressure ulcer of right ankle L L Pressure ulcer of left ankle L L Pressure ulcer of heel L L Pressure ulcer of right heel L L Pressure ulcer of left heel L L Pressure ulcer of head L L Pressure ulcer of other site L L89.94 Pressure ulcer of unspecified site T79.8XXA - T79.8XXS Other early complications of trauma T81.89XA - T81.89XS Other complications of procedures, not elsewhere classified *Current Procedural Terminology (CPT) 2014 American Medical Association: Chicago, IL. Clinical Coverage Guideline page 11

12 REFERENCES Peer Reviewed 1. Hayes Directory. (2010, May 5). Hyperbaric oxygen therapy for soft tissue radiation injuries [updated on March 6, 2014]. Retrieved from 2. Hayes Directory. (2008, December 22). Hyperbaric oxygen therapy for carbon monoxide poisoning [archived on January 22, 2014]. Retrieved from 3. Hayes Directory. (2009, July 16). Hyperbaric oxygen therapy for autistic disorder [updated on May 21, 2014]. Retrieved from Government Agencies, Professional and Medical Organizations 1. Centers for Medicare and Medicaid Services. (2006, June 19). National coverage determination for hyperbaric oxygen therapy (20.29). Retrieved from 2. Office of Health Insurance Programs, Division of Utilization Management and Provider Relations. (2008, March). New York state Medicaid topical oxygen wound therapy guidelines. Retrieved from 20Topical%20Oxygen%20Wound%20Therapy%20Guidelines.pdf Other 1. UnitedHealthcare Technology Assessment , February 19). Hyperbaric oxygen therapy. MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS Date Action 7/10/2014 8/1/2013 8/2/ /1/2011 8/2/2011 Approved by MPC. Combined items for topical oxygen wound therapy (previously HS 065). Approved by MPC. No changes. Approved by MPC. No changes. New template design approved by MPC. Approved by MPC. No changes. Clinical Coverage Guideline page 12