Topical hyperbaric oxygen therapy is considered investigational.
Systemic hyperbaric oxygen pressurization may be considered medically necessary in the treatment of the following conditions:
nonhealing diabetic wounds of the lower extremities in patients who meet the following 3 criteria:
Individual has type 1 or type 2 diabetes and has a lower-extremity wound due to diabetes;
Individual has a wound classified as Wagner grade 3 or higher (see Policy Guidelines section); and
Individual has no measurable signs of healing after 30 days of an adequate course of standard wound therapy;
acute traumatic ischemia (eg, crush injuries, reperfusion injury, compartment syndrome);
decompression sickness;
gas embolism, acute;
cyanide poisoning, acute;
acute carbon monoxide poisoning;
soft-tissue radiation necrosis (eg, radiation enteritis, cystitis, proctitis) and osteoradionecrosis;
pre- and posttreatment for patients undergoing dental surgery (non-implant-related) of an irradiated jaw;
gas gangrene (ie, clostridial myonecrosis);
profound anemia with exceptional blood loss: only when blood transfusion is impossible or must be delayed;
autism spectrum disorder;
chronic refractory osteomyelitis; and
compromised skin grafts or flaps.
Systemic hyperbaric oxygen pressurization is considered investigational in all other situations, including but not limited to, the treatment of the following conditions:
acute osteomyelitis;
bisphosphonate-related osteonecrosis of the jaw;
necrotizing soft tissue infections;
acute thermal burns;
acute surgical and traumatic wounds not meeting criteria specified in the medically necessary statement;
chronic wounds, other than those in patients with diabetes who meet the criteria specified in the medically necessary statement;
spinal cord injury;
traumatic brain injury;
inflammatory bowel disease (Crohn disease or ulcerative colitis);
brown recluse spider bites;
bone grafts;
carbon tetrachloride poisoning, acute;
cerebrovascular disease, acute (thrombotic or embolic) or chronic;
fracture healing;
hydrogen sulfide poisoning;
intra-abdominal and intracranial abscesses;
lepromatous leprosy;
meningitis;
pseudomembranous colitis (antimicrobial agent-induced colitis);
radiation myelitis;
sickle cell crisis and/or hematuria;
demyelinating diseases (eg, multiple sclerosis, amyotrophic lateral sclerosis);
retinal artery insufficiency, acute;
retinopathy, adjunct to scleral buckling procedures in patients with sickle cell peripheral retinopathy and retinal detachment;
pyoderma gangrenosum;
acute arterial peripheral insufficiency;
acute coronary syndromes and as an adjunct to coronary interventions, including but not limited to, percutaneous coronary interventions and cardiopulmonary bypass;
idiopathic sudden sensorineural hearing loss;
refractory mycoses: mucormycosis, actinomycosis, conidiobolus coronato;
cerebral edema, acute;
migraine;
in vitro fertilization;
cerebral palsy;
tumor sensitization for cancer treatments, including but not limited to, radiotherapy or chemotherapy;
delayed-onset muscle soreness;
idiopathic femoral neck necrosis;
chronic arm lymphedema following radiotherapy for cancer;
radiation-induced injury in the head and neck, except as noted earlier in the medically necessary statement;
early treatment (beginning at completion of radiotherapy) to reduce adverse events of radiotherapy;
Bell palsy;
acute ischemic stroke;
motor dysfunction associated with stroke;
herpes zoster;
vascular dementia;
fibromyalgia; and
mental illness (ie, posttraumatic stress disorder, generalized anxiety disorder or depression).
