Prior Authorization of Non-Emergent Hyperbaric Oxygen
06/19/2019 - Final Evaluation Report
The Centers for Medicare & Medicaid Services (CMS) released the Evaluation of the Medicare Prior Authorization Model for Non-emergent Hyperbaric Oxygen (HBO): Final Report. An evaluation of the model was conducted as required by Section 1115A of the Social Security Act. The findings indicate that prior authorization decreased HBO therapy use and expenditures; however, there was no significant effect on total Medicare expenditures. Additionally, the effects of the model on quality of care and adverse outcomes were neutral.
Please click on the following to view the Final Evaluation and related reports.
10/26/2018 - Spending and Affirmation Rate Results
CMS is releasing updated spending and affirmation rates for the Prior Authorization Model for Non-Emergent HBO Therapy. Please see the Status Update in the "Downloads" section below.
The Prior Authorization Model for Non-Emergent HBO Therapy will end as scheduled on February 28, 2018, based on date of service. Facilities and beneficiaries may continue to submit prior authorization requests after February 28, 2018 for treatments occurring prior to March 1, 2018. The independent evaluation of the model is ongoing. Results will be available once completed.
09/29/2017 - Diagnosis Code M27.8
Effective October 2, 2017, ICD-10 diagnosis code M27.8 will be covered under the HBO therapy national coverage determination (NCD) 20.29, retroactive to October 1, 2015. While this diagnosis code relates to a condition applicable for prior authorization, ICD-10 diagnosis code M27.8 will not be added to the prior authorization program. HBO therapy patients with this diagnosis will not be a part of the prior authorization program and claims may be submitted under the normal Medicare process.
First Year Data
CMS is releasing results from the first year of the Non-Emergent HBO Therapy Prior Authorization Model. Please see the Status Update in the "Downloads" section below.
Prior authorization does not create new clinical documentation requirements. Instead, it requires the same information necessary to support Medicare payment, just earlier in the process. Prior authorization allows providers and suppliers to address issues with claims prior to rendering services and to avoid an appeal process.
Effective December 28, 2015, the condition of preparation and preservation of compromised skin grafts is no longer included in this model. Prior authorization should not be requested for this condition.
The following conditions are available for prior authorization:
- Preparation and preservation of compromised skin grafts (not for primary management of wounds),
- Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management,
- Osteoradionecrosis as an adjuct to conventional treatment,
- Soft Tissue radionecrosis as an adjunct to conventional treatment,
- Actinomycrosis only as an adjunct conventional therapy when the disease process is refractory to antibiotics and surgical treatment, and
- Diabetic wounds of the lower extremities in patients who meet the following three criteria:
- Patient has Type I or Type II diabetes and who has a lower extremity wound that is due to diabetes
- patient has a wound classified as Wagner grade III or higher
- Patient has failed an adequate course of wound therapy as defined in the NCD.
Facilities and beneficiaries in Michigan began submitting prior authorization requests on March 1, 2015 for treatments occurring on or after April 13, 2015. All non-emergent hyperbaric oxygen therapy claims in the state of Michigan with a date of service on or after April 13, 2015 must have completed the prior authorization process or the claims will be subjected to prepayment review.
Facilities and beneficiaries in Illinois and New Jersey began submitting prior authorization requests on July 15, 2015 for treatments occurring on or after August 1, 2015. All non-emergent hyperbaric oxygen therapy claims in the states of Illinois and New Jersey with a date of service on or after August 1, 2015 must complete the prior authorization process or the claims will be subjected to prepayment review.
Questions can be sent to: HBOPA@cms.hhs.gov.
For additional information please refer to the link and download sections below.