POLICY . . . . . . . . PG-0205 EFFECTIVE . . . . . .01/01/13 LAST REVIEW . . . 03/10/15

MEDICAL POLICY Hyperbaric Oxygen Therapy (HBO)

GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement.

DESCRIPTION Hyperbaric Oxygen (HBO) therapy involves the systemic administration of pure gaseous oxygen under pressures greater than 1 atmosphere in a specialized chamber. 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. HBO therapy is limited to that which is administered in a chamber (including the one-man unit). Due to the equipment involved, this is performed either in an inpatient or outpatient hospital setting.

POLICY HBO Therapy (99183 & G0277) that meets medically indicated criteria below does not require prior authorization. Procedures A4575 and E0446 are non-covered. HBO therapy coverage is warranted for the following conditions: 1. Acute carbon monoxide intoxication (986) 2. Decompression illness (993.2, 993.3) 3. Gas embolism (958.0, 999.1) 4. Gas gangrene (040.0) 5. Acute traumatic peripheral ischemia (902.53, 903.01, 903.1, 904.0, 904.41) 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 6. Crush injuries and suturing of severed limbs (927.00-927.03, 927.09-927.11, 927.20-927.21, 927.8-927.9, 928.00-928.01, 928.10-928.11, 928.20-928.21, 928.3, 928.8-928.9, 929.0, 929.9, 996.90-996.99). As in previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened 7. Progressive necrotizing infections (necrotizing fasciitis) (728.86) 8. Acute peripheral arterial insufficiency (444.21, 444.22, 444.81) 9. Preparation and preservation of compromised skin grafts (not for primary management of wounds, coverage is limited to attempts to preserve an existing skin graft which is compromised) excludes artificial skin graft (996.52) 10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management (730.10730.19) 11. Osteoradio-necrosis as an adjunct to conventional treatment (526.89) 12. Soft tissue radio-necrosis as an adjunct to conventional treatment (990) 13. Cyanide Poisoning (987.7, 989.0) 14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment (039.0-039.4, 039.8, 039.9) 15. 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 (249.70-249.71, 250.70-250.83, 707.10-707.19, 707.20-707.25) C. Patient has failed an adequate course of standard wound therapy

-2-

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  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. Non-coverage Topical application of oxygen (A4575) does not meet the definition of HBO therapy. The clinical efficacy of this has not been established, and is considered experimental. Devices used in the topical application of oxygen (E0446) are also considered experimental. Therefore, no reimbursement is warranted. An E/M service is not expected to be billed on the same day as HBO treatment unless there is a concurrent medical problem. Documentation must include the examination findings to support a separately identifiable concurrent problem. Wound assessment, wound monitoring, and redressing of the wound, in addition to an assessment of the patient, cardiopulmonary stability and general clinical condition prior to the initiation of the therapy, is an integral part of the HBO treatment. HMO, PPO, Individual Marketplace, Elite, Advantage HBO Therapy (99183 & G0277) is covered when the criteria listed above is met. When the criteria above is not met, these services will be denied. Procedures A4575 and E0446 are non-covered.

CODING/BILLING INFORMATION The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered.

CPT CODE 99183 Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session HCPCS CODES A4575 Topical hyperbaric oxygen chamber, disposable E0446 Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories G0277 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval ICD-9-CM CODES 039.0- 039.9 Actinomycotic infections 040.0 Gas gangrene 249.70 Secondary diabetes mellitus with peripheral circulatory disorders, not stated as uncontrolled, or unspecified 249.71 Secondary diabetes mellitus with peripheral circulatory disorders, uncontrolled 250.70-250.73 Diabetes mellitus with peripheral circulatory disorders 250.80-250.83 Diabetes mellitus with other specified manifestations 444.21-444.81 Arterial embolism and thrombosis 526.89 Other specified diseases of the jaws 707.10-707.19 Ulcer of lower limb, except pressure ulcer 707.20-707.24 Pressure ulcer stages 728.86 Necrotizing fasciitis 730.10-730.19 Chronic osteomyelitis 902.53 Injury to iliac artery

-3903.01 903.1

Injury to axillary artery Injury to brachial blood vessels

904.0

Injury to common femoral artery

904.41 927.00-929.9 958.0 986 987.7 989.0 990 993.2 993.3 996.52 996.90-996.99 999.1

Injury to popliteal artery Crushing injury Air embolism as an early complication of trauma Toxic effect of carbon monoxide Toxic effect of hydrocyanic acid gas Toxic effect of hydrocyanic acid and cyanides Effects of radiation, unspecified Other and unspecified effects of high altitude Caisson disease Mechanical complication due to other tissue graft, not elsewhere classified Complications of reattached upper extremity or body part Air embolism as a complication of medical care, not elsewhere classified

ICD-10-CM CODES; EFFECTIVE 10/01/2015 A42.0- A42.2 Actinomycosis A42.81- A43.9 Actinomycosis A48.0 Gas gangrene B47.1 Actinomycetoma B47.9 Mycetoma, unspecified E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E08.59 Diabetes mellitus due to underlying condition with other circulatory complications E08.65 Diabetes mellitus due to underlying condition with hyperglycemia E09.51 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E09.59 Drug or chemical induced diabetes mellitus with other circulatory complications E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E10.618Type 1 diabetes mellitus with other specified complications E10.638 E10.649 Type 1 diabetes mellitus with hypoglycemia without coma E10.65 Type 1 diabetes mellitus with hyperglycemia E10.69 Type 1 diabetes mellitus with other specified complication E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E11.618Type 2 diabetes mellitus E11.638 E11.649 Type 2 diabetes mellitus with hypoglycemia without coma E11.65 Type 2 diabetes mellitus with hyperglycemia E11.69 Type 2 diabetes mellitus with other specified complication E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.59 Other specified diabetes mellitus with other circulatory complications E13.618Other specified diabetes mellitus E13.638 E13.649 Other specified diabetes mellitus with hypoglycemia without coma E13.65 Other specified diabetes mellitus with hyperglycemia E13.69 Other specified diabetes mellitus with other specified complication I70.231- I70.249 Atherosclerosis of native arteries I70.331-I70.349 Atherosclerosis of unspecified type of bypass graft(s) I70.431-I70.449 Atherosclerosis of autologous vein bypass graft(s) I70.531- I70.549 Atherosclerosis of nonautologous biological bypass graft(s) I70.631- I70.649 Atherosclerosis of nonbiological bypass graft(s) I70.731- I70.749 Atherosclerosis of other type of bypass graft(s) I74.2- I74.5 Embolism and thrombosis of other and unspecified parts of aorta L08.1 Erythrasma L89.000-L89.95 Pressure ulcer

-4L97.101L97.929 M27.8 M72.6 M86.30- M86.8x9 S35.511A S35.512A S35.513A S45.001A S45.002A S45.009A S45.011A S45.012A S45.019A S45.091A S45.092A S45.099A S45.101A S45.102A S45.109A S45.111A S45.112A S45.119A S45.191A S45.192A S45.092A S45.099A S45.101A S45.102A S45.109A S45.111A S45.112A S45.119A S45.191A S45.192A S47.1xxA S47.2xxA S47.9xxA S57.00xA S57.01xA S57.02xA S57.80xA S57.81xA S57.82xA S67.20xA S67.21xA S67.22xA S67.30xA S67.31xA S67.32xA S67.40xA S67.41xA S67.42xA S67.90xA S67.91xA S67.92xA S75.001A S75.002A S75.009A S75.011A S75.012A S75.019A

Non-pressure chronic ulcer Other specified diseases of jaws Necrotizing fasciitis Osteomyelitis Injury of right iliac artery, initial encounter Injury of left iliac artery, initial encounter Injury of unspecified iliac artery, initial encounter Unspecified injury of axillary artery, right side, initial encounter Unspecified injury of axillary artery, left side, initial encounter Unspecified injury of axillary artery, unspecified side, initial encounter Laceration of axillary artery, right side, initial encounter Laceration of axillary artery, left side, initial encounter Laceration of axillary artery, unspecified side, initial encounter Other specified injury of axillary artery, right side, initial encounter Other specified injury of axillary artery, left side, initial encounter Other specified injury of axillary artery, unspecified side, initial encounter Unspecified injury of brachial artery, right side, initial encounter Unspecified injury of brachial artery, left side, initial encounter Unspecified injury of brachial artery, unspecified side, initial encounter Laceration of brachial artery, right side, initial encounter Laceration of brachial artery, left side, initial encounter Laceration of brachial artery, unspecified side, initial encounter Other specified injury of brachial artery, right side, initial encounter Other specified injury of brachial artery, left side, initial encounter Other specified injury of axillary artery, left side, initial encounter Other specified injury of axillary artery, unspecified side, initial encounter Unspecified injury of brachial artery, right side, initial encounter Unspecified injury of brachial artery, left side, initial encounter Unspecified injury of brachial artery, unspecified side, initial encounter Laceration of brachial artery, right side, initial encounter Laceration of brachial artery, left side, initial encounter Laceration of brachial artery, unspecified side, initial encounter Other specified injury of brachial artery, right side, initial encounter Other specified injury of brachial artery, left side, initial encounter Crushing injury of right shoulder and upper arm, initial encounter Crushing injury of left shoulder and upper arm, initial encounter Crushing injury of shoulder and upper arm, unspecified arm, initial encounter Crushing injury of unspecified elbow, initial encounter Crushing injury of right elbow, initial encounter Crushing injury of left elbow, initial encounter Crushing injury of unspecified forearm, initial encounter Crushing injury of right forearm, initial encounter Crushing injury of left forearm, initial encounter Crushing injury of unspecified hand, initial encounter Crushing injury of right hand, initial encounter Crushing injury of left hand, initial encounter Crushing injury of unspecified wrist, initial encounter Crushing injury of right wrist, initial encounter Crushing injury of left wrist, initial encounter Crushing injury of unspecified wrist and hand, initial encounter Crushing injury of right wrist and hand, initial encounter Crushing injury of left wrist and hand, initial encounter Crushing injury of unspecified part(s) of unspecified wrist, hand and fingers, initial encounter Crushing injury of unspecified part(s) of right wrist, hand and fingers, initial encounter Crushing injury of unspecified part(s) of left wrist, hand and fingers, initial encounter Unspecified injury of femoral artery, right leg, initial encounter Unspecified injury of femoral artery, left leg, initial encounter Unspecified injury of femoral artery, unspecified leg, initial encounter Minor laceration of femoral artery, right leg, initial encounter Minor laceration of femoral artery, left leg, initial encounter Minor laceration of femoral artery, unspecified leg, initial encounter

-5S75.021A S75.022A S75.029A S75.091A S75.092A S75.099A S77.00xA S77.01xA S77.02xA S77.10xA S77.11xA S77.12xA S77.20xA S77.21xA S77.22xA S85.001A S85.002A S85.009A S85.011A S85.012A S85.019A S85.091A S85.092A S85.099A S87.00xA S87.01xA S87.02xA S87.80xA S87.81xA S87.82xA S97.00xA S97.01xA S97.02xA S97.101A S97.102A S97.109A S97.111A S97.112A S97.119A S97.121A S97.122A S97.129A S97.80xA S97.81xA S97.82xA T57.3x1A T57.3x2A T57.3x3A T57.3x4A T58.01xA T58.02xA T58.03xA T58.04xA T58.11xA T58.12xA T58.13xA T58.14xA T58.2x1A T58.2x2A T58.2x3A

Major laceration of femoral artery, right leg, initial encounter Major laceration of femoral artery, left leg, initial encounter Major laceration of femoral artery, unspecified leg, initial encounter Other specified injury of femoral artery, right leg, initial encounter Other specified injury of femoral artery, left leg, initial encounter Other specified injury of femoral artery, unspecified leg, initial encounter Crushing injury of unspecified hip, initial encounter Crushing injury of right hip, initial encounter Crushing injury of left hip, initial encounter Crushing injury of unspecified thigh, initial encounter Crushing injury of right thigh, initial encounter Crushing injury of left thigh, initial encounter Crushing injury of unspecified hip with thigh, initial encounter Crushing injury of right hip with thigh, initial encounter Crushing injury of left hip with thigh, initial encounter Unspecified injury of popliteal artery, right leg, initial encounter Unspecified injury of popliteal artery, left leg, initial encounter Unspecified injury of popliteal artery, unspecified leg, initial encounter Laceration of popliteal artery, right leg, initial encounter Laceration of popliteal artery, left leg, initial encounter Laceration of popliteal artery, unspecified leg, initial encounter Other specified injury of popliteal artery, right leg, initial encounter Other specified injury of popliteal artery, left leg, initial encounter Other specified injury of popliteal artery, unspecified leg, initial encounter Crushing injury of unspecified knee, initial encounter Crushing injury of right knee, initial encounter Crushing injury of left knee, initial encounter Crushing injury of unspecified lower leg, initial encounter Crushing injury of right lower leg, initial encounter Crushing injury of left lower leg, initial encounter Crushing injury of unspecified ankle, initial encounter Crushing injury of right ankle, initial encounter Crushing injury of left ankle, initial encounter Crushing injury of unspecified right toe(s), initial encounter Crushing injury of unspecified left toe(s), initial encounter Crushing injury of unspecified toe(s), initial encounter Crushing injury of right great toe, initial encounter Crushing injury of left great toe, initial encounter Crushing injury of unspecified great toe, initial encounter Crushing injury of right lesser toe(s), initial encounter Crushing injury of left lesser toe(s), initial encounter Crushing injury of unspecified lesser toe(s), initial encounter Crushing injury of unspecified foot, initial encounter Crushing injury of right foot, initial encounter Crushing injury of left foot, initial encounter Toxic effect of hydrogen cyanide, accidental (unintentional), initial encounter Toxic effect of hydrogen cyanide, intentional self-harm, initial encounter Toxic effect of hydrogen cyanide, assault, initial encounter Toxic effect of hydrogen cyanide, undetermined, initial encounter Toxic effect of carbon monoxide from motor vehicle exhaust, accidental (unintentional), initial encounter Toxic effect of carbon monoxide from motor vehicle exhaust, intentional self-harm, initial encounter Toxic effect of carbon monoxide from motor vehicle exhaust, assault, initial encounter Toxic effect of carbon monoxide from motor vehicle exhaust, undetermined, initial encounter Toxic effect of carbon monoxide from utility gas, accidental (unintentional), initial encounter Toxic effect of carbon monoxide from utility gas, intentional self-harm, initial encounter Toxic effect of carbon monoxide from utility gas, assault, initial encounter Toxic effect of carbon monoxide from utility gas, undetermined, initial encounter Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, accidental (unintentional), initial encounter Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, intentional self-harm, initial encounter Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, assault, initial encounter

-6T58.2x4A T58.8x1A T58.8x2A T58.8x3A T58.8x4A T58.91xA T58.92xA T58.93xA T58.94xA T65.0x1A T65.0x2A T65.0x3A T65.0x4A T66.xxxA T70.20xA T70.29xA T70.3xxA T79.0xxA T80.0xxA T86.820 T86.821 T86.822 T86.828 T86.829 T87.0x1 T87.0x2 T87.0x9 T87.1x1 T87.1x2 T87.1x9 T87.2

Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, undetermined, initial encounter Toxic effect of carbon monoxide from other source, accidental (unintentional), initial encounter Toxic effect of carbon monoxide from other source, intentional self-harm, initial encounter Toxic effect of carbon monoxide from other source, assault, initial encounter Toxic effect of carbon monoxide from other source, undetermined, initial encounter Toxic effect of carbon monoxide from unspecified source, accidental (unintentional), initial encounter Toxic effect of carbon monoxide from unspecified source, intentional self-harm, initial encounter Toxic effect of carbon monoxide from unspecified source, assault, initial encounter Toxic effect of carbon monoxide from unspecified source, undetermined, initial encounter Toxic effect of cyanides, accidental (unintentional), initial encounter Toxic effect of cyanides, intentional self-harm, initial encounter Toxic effect of cyanides, assault, initial encounter Toxic effect of cyanides, undetermined, initial encounter Radiation sickness, unspecified, initial encounter Unspecified effects of high altitude, initial encounter Other effects of high altitude, initial encounter Caisson disease [decompression sickness], initial encounter Air embolism (traumatic), initial encounter Air embolism following infusion, transfusion and therapeutic injection, initial encounter Skin graft (allograft) rejection Skin graft (allograft) (autograft) failure Skin graft (allograft) (autograft) infection Other complications of skin graft (allograft) (autograft) Unspecified complication of skin graft (allograft) (autograft) Complications of reattached (part of) right upper extremity Complications of reattached (part of) left upper extremity Complications of reattached (part of) unspecified upper extremity Complications of reattached (part of) right lower extremity Complications of reattached (part of) left lower extremity Complications of reattached (part of) unspecified lower extremity Complications of other reattached body part

REVISION HISTORY EXPLANATION 10/12/13: ICD-10 Codes added from ICD-9 conversion. Policy reviewed and updated to reflect most current clinical evidence. Approved by Medical Policy Steering Committee as revised. 03/10/15: Removed deleted code C1300 and added new code G0277. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Ohio Department of Medicaid http://jfs.ohio.gov/ American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets Industry Standard Review Hayes, Inc.