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National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy

For purposes of coverage under Medicare, Hyperbaric Oxygen Therapy (HBOT) is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. The patient is entirely enclosed in a pressure chamber breathing 100% oxygen (O2) at greater than one atmosphere (atm) pressure. Either a mono-place chamber pressurized with pure O2 or a larger multi-place chamber pressurized with compressed air where the patient receives pure O2 by mask, head tent, or endotracheal tube may be used.

Local Coverage Article: Hyperbaric Oxygen Therapy – Medical Policy Article (L36504)

  • 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 the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened.
  • Progressive necrotizing infections (necrotizing fasciitis),
  • Acute peripheral arterial insufficiency,
  • Preparation and preservation of compromised skin grafts (not for primary management of wounds),
  • Chronic 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 antibiotics and surgical treatment,
  • Diabetic wounds of the lower extremities in patients who meet the following three criteria:
    a. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
    b. Patient has a wound classified as Wagner grade III or higher; and
    c. 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.