1. The CPT code for physician attendance and supervision for each HBOT session is 99183
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1 Subject: Hyperbaric Oxygen Therapy* Updated: February 23, 2010 Department(s): Utilization Management Policy: Objective: Systemic hyperbaric oxygen therapy (HBOT) is reimbursable under plans administered by QualCare, Inc. To assure proper and consistent reimbursement for a service with specific indications Procedure: 1. The CPT code for physician attendance and supervision for each HBOT session is The HCPCS code for each 30-minute session in the hyperbaric chamber is C The conditions for which HBOT is reimbursable include, but are not limited to, the following: a. Non-healing infected deep wounds of the lower extremity (reaching tendons or bone) that have not responded to at least 4 weeks of wound care that includes debridement, intensive antibiotic therapy, and appropriate management of ischemia b. Acute carbon monoxide poisoning (ICD-9 986) c. Decompression sickness ( the bends ) (993.3)
2 d. Acute air or other gas embolism (673.0, 958.0, 999.1) e. Acute peripheral ischemia, including but not limited to compartment syndrome (958.9, 729.7) f. Progressive necrotizing soft tissue infections, including but not limited to Clostridial myonecrosis (728.8) g. Chronic refractory osteomyelitis unresponsive to conventional medical and surgical therapy (730.1) h. Compromised skin grafts and flaps (996.5) i. Radiation necrosis, with HBOT as an adjunct to conventional treatment j. Radiation-induced enteritis or proctitis (558.1) k. Overwhelming blood loss anemia when transfusion is not possible (285.1) l. Pneumatosis cystoides intestinalis (569.8) m. Prophylactic pre- and post-treatment in association with dental surgery of an irradiated jaw n. Acute cerebral edema (348.5) o. Brain abscess (324.0) 4. HBOT is NOT reimbursable for a number of conditions, including but not limited to the following, as the lack of a sufficient body of peer-reviewed literature supporting its efficacy for these conditions causes it to be deemed experimental, investigational, or unproven: a. Radiation-induced hemorrhagic cystitis (595.82) b. Breast irradiation-related pain, edema, and/or erythema (611.0) c. Radiation-induced brachial plexopathy (353.0, 953.4) d. Autism (299.0) e. Necrotizing arachnidism (998.5, E905.1) f. Reflex sympathetic dystrophy (complex regional pain syndrome ( ) g. Cerebral palsy ( ) h. Lyme disease(088.81) 5. Topical oxygen therapy or topical hyperbaric oxygen therapy (HCPCS A4575) for the treatment of chronic, nonhealing wounds is not reimbursable, as there is not a sig- 2
3 nificant body of refereed literature supporting its efficacy. It is therefore deemed experimental, investigational, and unproven. 6. Proposed indications for HBOT that are not on the list in Section 3 above must be referred for medical review. a. Unless proposals for these non-listed indications are accompanied by peer-reviewed literature, reimbursement for HBOT will not be considered; b. When such proposals are accompanied by peerreviewed literature HBOT will not be reimbursable for these non-listed indications if, after medical review, HBOT is still deemed experimental, investigational or unproven for them. 7. Initial authorization of systemic HBOT shall not exceed one month. Treatment beyond one month shall require updated clinical information from the physician documenting the patient s response and continued medically-based need and must then be referred to the medical director. 8. Requests for HBOT beyond the second month must be accompanied by a recommendation by a vascular surgeon not involved in the initial management of the patient. References Rossignol DA. Novel and emerging treatments for autism spectrum disorders: A systematic review. Ann Clin Psychiatry 2009;21(4): (Oct-Dec) Williams ST, Davies A, Bryson P. Chornic regional pain syndrome after subtalar arthrodesis is not prevented by early hyperbaric oxygen. Pain Physician 2009;12(5):E335-E339 (Sep-Oct) Rosssignol DA, Rossignol LW, Smith S, et al. Hyperbaric treatment for children with autism: A multicenter, randomized, double-blind, controlled trial. BMC Pediatr 2009;13:9-21 (Mar) Hayes, Inc. Hayes Medical Technology Directory. Hyperbaric Oxygen Therapy for Autistic Disorder. Lansdale, PA: Hayes, Inc.; July 16,
4 Hampson NB, Rudd RA, Hauff NM. Increased long-term mortality among survivors of acute carbon monoxide poisoning. Crit Care Med. 2009;37(6): (Jun) Kaya A, Aydin F, Altay T, et al. Can major amputation rates be decreased in diabetic foot ulcers with hyperbaric oxygen therapy? Int Orthop 2009;33(2):441-6 (Apr) Hayes, Inc. Hayes Medical Technology Directory. Hyperbaric Oxygen Therapy for Soft Tissue Radiation Injuries. Lansdale, PA: Hayes, Inc.; March 25, 2009 Hayes, Inc. Hayes Medical Technology Directory. Hyperbaric Oxygen Therapy for Osteoradionecrosis. Lansdale, PA: Hayes, Inc.; March 12, 2009 George ME, Rueth NM, Skarda DE, et al. Hyperbaric oxygen does not improve outcome in patients with necrotizing soft tissue infection. Surg Infect 2009;10(1):21-8 (Feb) Hayes, Inc. Hayes Medical Technology Directory. Hyperbaric Oxygen Therapy for Carbon Monoxide Poisoning. Lansdale, PA: Hayes, Inc.; December 22, 2008 Duzgun AP, Satir HZ, Ozozan O, et al. Effect of hyperbaric oxygen therapy on healing of diabetic foot ulcers. J Foot Ankle Surg 2008;47(6):515-9 (Nov-Dec) Hayes, Inc. Hayes Medical Technology Directory. Hyperbaric Oxygen Therapy for Diabetic Foot Wounds. Lansdale, PA: Hayes, Inc.; September 15, 2008 Van Hoesen KB. Hyperbaric Medicine. Ch 71 in Auerbach PS. Wilderness Medicine 5 th ed. Philadelphia. Mosby Elsevier McDonagh MS, Morgan D,Carson S, et al. Systematic review of hyperbaric oxygen therapy for cerebral palsy: The state of the evidence. Dev Med Child Neurol 2007;49(12): (Dec) Buettner MF, Wolkenhauer D. Hyperbaric Oxygen Therapy in the Treastment of Open Fractures and Crush Injuries. Emerg Med Clin N Am 2007;25(1): (Feb) Mechem CC, Manaker S. Hyperbaric oxygen therapy. UpToDate OnLine /08/05. Available at Accessed 03/23/08 Tutrone WE, Green KM, Norris T, et al. Brown recluse spider envenomation: Dermatologic application of hyperbaric oxygen therapy. J Drugs Dermatol 2005;4(4): (Jul-Aug) Moody EJ, Simon BA, Johns RA. Therapeutic Gases. Ch 16 in Goodman & Gilman s Pharmacology, 10 th ed. New York: McGraw-Hill, 2001 p ( , accessed 8/11/05) Feldmeier JJ, Hopf HW, Warriner RA 3 rd, et al. UHMS position statement: Topical oxygen for chronic wounds. Undersea Hyperb Med 2005;323(3): (May-Jun) 4
5 Hayes, Inc. Hayes Medical Technology Directory. Topical Oxygen Therapy for Chronic Wound Healing. Lansdale, PA: Hayes, Inc.; January 8, 2002 Leach RM, Rees PJ, Wilmshurst P. ABC of oxygen: Hyperbaric oxygen therapy. BMJ 1998;317: (Oct 24) Tibbles PM, Edelsberg JS. Medical Progress: Hyperbaric-oxygen therapy. N Engl J Med 1996;334: (Jun 20) *Consistent with Summary Plan Description (SPD). When there is discordance between this policy and the SPD, the provisions of the SPD prevail. 5
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