HIGHMARK COMMERCIAL MEDICAL POLICY - DELAWARE

 
 
Medical Policy:
Z-3-015
Topic:
Hyperbaric Oxygen Therapy
Section:
Miscellaneous
Effective Date:
April 8, 2019
Issued Date:
April 8, 2019
Last Revision Date:
February 2019
Annual Review:
February 2019
 
 

Hyperbaric oxygen (HBO) therapy is a treatment in which the entire body is exposed to oxygen under increased atmospheric pressure. Full-body HBO therapy occurs in a single or multiple chambers with 100% systemic oxygen that has a pressurization of at least 1.4 atmospheres.

Policy Position

HBO therapy may be considered medically necessary for ANY of the following:

  • Actinomycosis refractory to antibiotics and surgical treatment; or
  • Anemia with exceptional blood loss; or
  • Carbon monoxide intoxication (acute); or
  • Chronic refractory osteomyelitis; or
  • Crush injuries and suturing of severed limbs, when loss of function, limb or life is threatened; or
  • Cyanide poisoning; or 
  • Decompression illness; or
  • Gas embolism; or
  • Gas gangrene; or
  • Necrotizing fasciitis; or
  • Osteoradionecrosis as an adjunct to conventional treatment; or
  • Peripheral arterial insufficiency (acute); or
  • Preparation and preservation of compromised skin grafts; or
    • This is not intended to cover preparation for an initial skin graft. Coverage is limited to attempts to preserve an existing skin graft which is compromised (i.e., showing signs of failure or rejection, dying tissue, etc).
  • Soft tissue radionecrosis as an adjunct to conventional treatment (e.g., radiation enteritis, cystitis, proctitis); or
  • Traumatic peripheral ischemia (acute), when loss of function, limb, or life is threatened; or
  • Prophylactic pre-and post-treatment for member undergoing dental surgery of a radiated jaw.

The use of HBO therapy is considered experimental/investigational and, therefore, non-covered for any indication not listed in the coverage criteria above. Scientific evidence does not support the efficacy and safety.

99183

G0277

 

 

 

 

 


HBO therapy may be considered medically necessary for the treatment of diabetic wounds of the lower extremities in individuals who meet EITHER of the following criteria:

  • Has Type I or Type II diabetes and has a lower extremity wound that is due to diabetes; or
  • Has a wound classified as Wagner grade III or higher; and
  • Has failed an adequate course of standard wound therapy:
    • The use of HBO therapy will be covered as an adjunctive therapy after there are no measurable signs of healing for greater than or equal to 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. Failure to respond to standard wound care occurs when there are no measurable signs of healing for greater than or equal to 30 consecutive days. Wounds must be evaluated every 30 days during administration of HBO therapy. Continued treatment with HBO treatment is not covered if measurable signs of healing have not been demonstrated within a 30-day treatment period.  

The use of HBO therapy is considered experimental/investigational and, therefore, non-covered for any indication not listed in the coverage criteria above. Scientific evidence does not support the efficacy and safety.

99183

G0277

 

 

 

 

 


Topical hyperbaric oxygen therapy is considered experimental/investigational and therefore non-covered.
Scientific evidence does not support the efficacy and safety.

 

A4575

 

 

 

 

 

 


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Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

HBO therapy is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



Links





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.




    Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

    Discrimination is Against the Law
    The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.