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Prior Authorization of Non-Emergent Hyperbaric Oxygen

Updates

09/29/2017 - Diagnosis Code M27.8

Effective October 2, 2017, ICD-10 diagnosis code M27.8 will be covered under the hyperbaric oxygen (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

The Centers for Medicare & Medicaid Services (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.

Background

CMS has implemented a prior authorization model for non-emergent HBO therapy in Illinois, Michigan, and New Jersey. CMS is testing whether prior authorization helps reduce expenditures, while maintaining or improving quality of care. CMS believes using a prior authorization process will help confirm that services are provided in compliance with applicable Medicare coverage, coding, and payment rules before services are rendered and claims are paid.  

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.