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Hyperbaric Oxygen Therapy

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:

Patient has type 1 or type 2 diabetes and has a lower-extremity wound due to diabetes;

Patient has a wound classified as Wagner grade 3 or higher (see Policy Guidelines section); and

Patient 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; and

chronic refractory osteomyelitis.

Autism spectrum disorder

Hyperbaric oxygen pressurization is considered investigational in all other situations, including but not limited to, the treatment of the following conditions:

compromised skin grafts or flaps;

acute osteomyelitis;

bisphosphonate-related osteonecrosis of the jaw;

necrotizing soft tissue infections;

acute thermal burns;

acute surgical and traumatic wounds;

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).

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