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Medical Policy: 02.01.13
Original Effective Date: September 1999
Reviewed: August 2011
Revised: August 2011
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Hyperbaric oxygen therapy (HBO) is a technique of delivering higher pressures of oxygen to the tissues. Two methods of administration are currently available. In systemic hyperbaric oxygen administration, the patient is entirely enclosed in a pressure chamber and breathes oxygen at a pressure greater than 1 atmosphere (the pressure of oxygen at sea level). This technique relies on systemic circulation to deliver highly oxygenated blood to target tissues. Systemic hyperbaric oxygen therapy is used to treat wounds as well as systemic illnesses such as air or gas embolism, carbon monoxide poisoning, and clostridial gas gangrene.
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 theorized that the high concentrations of oxygen diffuse directly into the wound to increase the local cellular oxygen tension, which in turn, promotes healing. The pressurized oxygen is delivered via an appliance secured over the wound site. Topical hyperbaric oxygen therapy has been investigated as a treatment of skin ulcerations due to diabetes, venous stasis, postsurgical infections, decubitus ulcers, burns, and frostbite.
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Prior Approval:
Not applicable
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Policy:
Topical hyperbaric oxygen therapy is considered investigational for all applications.
Systemic hyperbaric oxygen therapy (HBO) may be considered medically necessary in the treatment of the following conditions:
- Decompression sickness
- Acute carbon monoxide poisoning
- Gas gangrene (i.e., clostridial myonecrosis)
- Crush injury with acute traumatic ischemia
- Radiation necrosis (osteoradionecrosis and soft tissue radiation necrosis)
- Acute osteomyelitis, refractory to standard medical treatment
- Compromised skin grafts or flaps
- Prophylactic pre-operative and post-operative treatment for patients undergoing dental surgery of a radiated jaw
- Chronic non-healing wounds
- Profound anemia with exceptional blood loss: only when blood transfusion is impossible or must be delayed
- Acute cyanide poisoning
- Air or gas embolism
- Progressive necrotizing infections (necrotizing fascitis)
- Acute peripheral arterial insufficiency
- Chronic osteomyelitis refractory to conventional medical and surgical management
- Acute traumatic peripheral ischemia
- Actinomycosis, only when refractory to antibiotics and surgical treatment
- Diabetic wounds of the lower extremities meeting all of the following criteria:
- Type I or II diabetes mellitus
- Wound classification as Wagner grade III or higher
- History of failed standard wound therapy
Systemic hyperbaric Oxygen Therapy (HBO) is considered investigational for all indications not listed above including, but not limited to, the following diagnoses or circumstances:
- Acute cerebral edema
- Acute thermal burns
- Other refractory mycoses, Conidiobolus coronata
- Severe or refractory Crohn's disease
- Migraine headache
- Cerebral palsy
- Acute coronary syndromes with percutaneous coronary interventions
- Idiopathic sensorineural hearing loss
- In vitro fertilization
- Neurologic conditions
- Cerebrovascular accident (436)
- Bone graft (V45.89)
- Acute carbon tetrachloride poisoning
- Fracture healing
- Hydrogen sulfide poisoning
- Intra-abdominal and intracranial abscesses
- Lepromatous leprosy
- Meningitis
- Pseudomembranous colitis (antimicrobial agent-induced colitis)
- Radiation myelitis, cystitis, enteritis, or proctitis
- Multiple sclerosis
- Retinal artery insufficiency, acute
- Retinopathy, adjunct to scleral buckling procedures in patients with sickle cell peripheral retinopathy and retinal detachment
- Pyoderma gangrenosum
- Sickle cell crisis and/or hematuria
- Head and spinal cord injury traumatic
- Brown recluse spider bites
- Early treatment (beginning at the completion of radiation therapy) to reduce side effects of radiation therapy
- Autism spectrum disorders
- Idiopathic femoral head necrosis
- Chronic arm lymphedema following radiotherapy for cancer
- Radiation-induced injury of the head and neck
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Procedure Codes and Billing Guidelines:
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session
- A4575 may be used to report topical hyperbaric oxygen therapy
- C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval
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Selected References:
- Landau Z. Topical hyperbaric oxygen and low energy laser for the treatment of diabetic foot ulcers. Archives of Orthopaedic and Trauma Surgery 1998;117:156-158
- Leslie CA, Sapico FL, Ginunas VJ, Adkins RH. Randomized controlled trial of topical hyperbaric oxygen for treatment of diabetic foot ulcer. Diabetes Care 1988; 11:111-115.
- Colombel JF, Bouault JM, Lesage X, Zavadil P, Quandalle P, Cortot A. Hyperbaric oxygenation in severe perineal Crohn's disease. Diseases of the Colon and Rectum 1995; 38:609-614.
- Lambert PM, Intriere N, Eichstaedt R. Management of dental extractions in irradiated jaws: A protocol with hyperbaric oxygen therapy. Journal of Oral and Maxillofacial Surg 1997; 55:268-274.
- Sipahi AM, Damiao AOMC, de Sousa MM, Barbutti RC, Trivellato S, Esteves C, D'Agostino M, Laudanna AA. Hyperbaric Oxygen: A new alternative in the treatment of perianal Crohns disease. Revista do Hospital das Clinicas; Faculdade de Medicina de Universidade de Sao Paulo. 1996; 51(5):189-191.
- TEC Assessment. Hyperbaric oxygen therapy for wound healing June 1999.
- Wilkerson R, Paull W, Coville FV. Necrotizing Fasciitis; review of the literature and case report. Clinical Orthopedics and related research March 1987;216: 187-192.
- 35-10 Hyperbaric Oxygen Therapy. Medicare Coverage Issues Manual. http://www.hcfa.gov/pubforms/06_cim/ci35.htm
- Bakker D. Selected Aerobic and Anaerobic Soft Tissue Infections. In E.P. Kindwall and H.T. Whelan ( eds.), Hyperbaric Medicine Practice (pp. 575-597) Flagstaff, AZ: Best Pub. Co.
- Guidelines for management of wounds in patients with lower-extremity arterial disease. Wound Ostomy and Continence Nurses Society, Glenview,IL. June 2002. Summary from National Guideline Clearinghouse, available online:http://www.guidelines.gov; accessed 1/5/2004.
- Gordillo GM, Sen CK. Revisiting the essential role of oxygen in wound healing. Am J Surg. 186 (2003) 259-263.
- Sheikh AY, Gibson JJ, Rollins MD, Hopf HW, Hussain Z, Hunt TK. Effect of Hyperoxia on Vascular Endothelial Growth Factor Levels in a Wound Model. Arch Surg. 2000;135:1293-1297.
- TARGET [database online]. Plymouth Meeting (PA): ECRI; August 2006 Hyperbaric oxygen therapy (HBOT) for acute soft tissue injury. TARGET Report 917. Available: http://www.ecri.org.
- TARGET [database online]. Plymouth Meeting (PA): ECRI; September 2006 Hyperbaric oxygen therapy (HBOT) for traumatic brain injury (TBI). TARGET Report 918. Available: http://www.ecri.org.
- ECRI. Hyperbaric Oxygen Therapy for Brain Injury, Stroke, Multiple Sclerosis, Cerebral Palsy, and Autism. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 January 8. 13p. (ECRI Hotline Response). Also available: http://www.ecri.org.
- ECRI. Hyperbaric Oxygen Therapy for Chronic Wound Healing. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2007 August 23. 11p. (ECRI Hotline Response). Also available: http://www.ecri.org.
- ECRI. Hyperbaric Oxygen Therapy for Soft Tissue Radionecrosis. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 January 8. 10p. (ECRI Hotline Response). Also available: http://www.ecri.org.
- ECRI. Hyperbaric Oxygen Therapy for Hemorrhagic Cystitis. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2007 September 20. 7p. (ECRI Hotline Response). Also available: http://www.ecri.org.
- Rossignol DA, Rossignol LW, Smith S et al. Hyperbaric treatment for children with autism: a multicenter, randomized, double-blind controlled trial. BMC Pediatrics 2009; 9:21.
- Bennett M, Hart B. UHMS Position paper. Treatment of children with autism spectrum disorder with hyperbaric oxygen therapy. December 5, 2009. Available on UMHS website, www.uhms.org
- Londahl M, Landin-Olsson M, Katzman P. Hyperbaric oxygen therapy improves health-related quality of life in patients with diabetes and chronic foot ulcer. Diabet Med. 2011 Feb;28(2):186-90. doi: 10.1111/j.1464-5491.2010.03185.x.
- Londahl M, Katzman P, Hammarlund C et al. Relationship between ulcer healing after hyperbaric oxygen therapy and transcutaneous oximetry, toe blood pressure and ankle-brachial index in patients with diabetes and chronic foot ulcers. Diabetologia. 2001 Jan;54(1):65-8. Epub 2010 Oct 9.
- Eskes A, Ubbink DT, Lubbers M et al. Hyperbaric oxygen therapy for treating acute surgical and traumatic wounds. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD008059.
- Spiegelberg L, Djasim UM, van Neck HW et al. Hyperbaric oxygen therapy in the management of radiation-induced injury in the head and neck region: a review of the literature. J Oral Maxillofac Surg. 2010 Aug;68(8):1732-9. Epub 2010 May 20.
- Gothard L, Haviland J, Bryson P et al. Randomised phase II trial of hyperbaric oxygen therapy in patients with chronic arm lymphedema after radiotherapy for cancer. Radiother Oncol. 2010 Oct;97(1):101-7. Epub 2010 May 31.
- Camporesi EM, Vezzani G, Bosco G et al. Hyperbaric oxygen therapy in femoral head necrosis. J Arthroplasty. 2010 Sep;25(6 Suppl):118-23. Epub 2010 Jul 15.
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Policy History:
Date Reason Action
August 2011 Annual review Policy revised
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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