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Medicare coverage policy for HBO therapy - Coverage Manual 35-10

For purposes of coverage under Medicare, hyperbaric oxygen (HBO) therapy is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure.


A. Covered Conditions.--Program reimbursement for HBO therapy will be limited to that which is administered in a chamber (including the one man unit) and is limited to the following conditions:

  1. Acute carbon monoxide intoxication, (ICD-9 -CM diagnosis 986).
2. Decompression illness, (ICD-9-CM diagnosis 993.2, 993.3).
3. Gas embolism, (ICD-9-CM diagnosis 958.0, 999.1).
4. Gas gangrene, (ICD-9-CM diagnosis 0400).
5. 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. (ICD-9-CM diagnosis 902.53, 903.01, 903.1, 904.0, 904.41.)
6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened. (ICD-9-CM diagnosis 927.00-927.03,
927.09-927.11, 927.20-927.21, 927.8-927.9, 928.00-928.01, 928.10-928.11, 928.20-928.21, 928.3, 928.8-928.9, 929.0, 929.9, 996.90- 996.99.)
7. Progressive necrotizing infections (necrotizing fasciitis), (ICD-9-CM diagnosis 728.86).
8. Acute peripheral arterial insufficiency, (ICD-9-CM diagnosis 444.21, 444.22, 444.81).
9. Preparation and preservation of compromised skin grafts (not for primary management of wounds), (ICD-9CM diagnosis 996.52; excludes artificial skin graft).
10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management, (ICD-9-CM diagnosis 730.10-730.19).
11. Osteoradionecrosis as an adjunct to conventional treatment, (ICD-9-CM diagnosis 526.89).
12. Soft tissue radionecrosis as an adjunct to conventional treatment, (ICD-9-CM diagnosis 990).
13. Cyanide poisoning, (ICD-9-CM diagnosis 987.7, 989.0).
14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment, (ICD-9-CM diagnosis 039.0-039.4, 039.8, 039.9).


B. Noncovered Conditions.--All other indications not specified under ¡±35-10 (A) are not covered under the Medicare program. No program payment may be made for any conditions other than those listed in ¡± 35-10 (A). No program payment may be made for HBO in the treatment of the following conditions:

  1. Cutaneous, decubitus, and stasis ulcers.
2. Chronic peripheral vascular insufficiency.
3. Anaerobic septicemia and infection other than clostridial.
4. Skin burns (thermal).
5. Senility.
6. Myocardial infarction.
7. Cardiogenic shock.
8. Sickle cell anemia.
9. Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency.
10. Acute or chronic cerebral vascular insufficiency.
11. Hepatic necrosis.
12. Aerobic septicemia.
13. Nonvascular causes of chronic brain syndrome (Pick¡¦s disease, Alzheimer¡¦s disease, Korsakoff¡¦s disease).
14. Tetanus.
15. Systemic aerobic infection.
16. Organ transplantation.
17. Organ storage.
18. Pulmonary emphysema.
19. Exceptional blood loss anemia.
20. Multiple Sclerosis.
21. Arthritic Diseases.
22. Acute cerebral edema.


C. Reasonable Utilization Parameters.--Make payment where HBO therapy is clinically practical. HBO therapy should not be a replacement for other standard successful therapeutic measures. Depending on the response of the individual patient and the severity of the original problem, treatment may range from less than 1 week to several months duration, the average being 2 to 4 weeks. Review and document the medical necessity for use of hyperbaric oxygen for more than 2 months, regardless of the condition of the patient, before further reimbursement is made.


D. Topical Application of Oxygen.--This method of administering oxygen does not meet the definition of HBO therapy as stated above. Also, its clinical efficacy has not been established. Therefore, no Medicare reimbursement may be made for the topical application of oxygen. (Cross refer: ¡±35-31. )


 
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