0129-Hyperbaric Oxygen Therapy for Diabetic Wounds: Medical Necessity and Documentation Requirements

Issue Name
0129-Hyperbaric Oxygen Therapy for Diabetic Wounds: Medical Necessity and Documentation Requirements
Date
Review Type
Complex
Provider Type
Outpatient Hospital
MAC Jurisdiction
All A/B MACs

Description

For purposes of coverage under Medicare, Hyperbaric Oxygen Therapy (HBOT) is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. The patient is entirely enclosed in a pressure chamber breathing 100% oxygen (O2) at greater than one atmosphere pressure. 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. Medical records will be reviewed to determine if Hyperbaric Oxygen Therapy (HBOT) is medically necessary according to Medicare coverage indications.

Affected Codes

G0277

Applicable Policy References

1.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3.    42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
4.    42 CFR §405.986- Good Cause for Reopening
5.    42 CFR §405.929- Post-Payment Review
6.    42 CFR §405.930- Failure to Respond to Additional Documentation Request
7.    42 Code of Federal Regulations §424.5- Basic Conditions, (a)(6)- Sufficient Information
8.    42 Code of Federal Regulations §411.15- Particular Services Excluded from Coverage, (k)- Any Services not Reasonable and Necessary, (1)
9.    CMS National Coverage Determination Manual, Chapter 1- Coverage determinations, §20.29- Hyperbaric Oxygen Therapy
10.    Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
11.    Novitas LCD L35021- Hyperbaric Oxygen (HBO) Therapy; Effective 10/01/2015; Revised 01/01/2020; Retired 8/27/2020
12.    Novitas LCA A56714 – Billing and Coding:  Hyperbaric Oxygen (HBO) Therapy; Effective 07/25/19; Retired 08/27/20
13.    First Coast Service LCD L36504- Hyperbaric Oxygen (HBO) Therapy; Effective 04/11/2016; Revised 11/28/2019; Retired 08/27/2020
14.    First Coast LCA A57800 – Billing and Coding:  Hyperbaric Oxygen (HBO) Therapy; Effective 10/03/18; Retired 08/27/20
15.    Annual American Medical Association CPT Manual, Coding Guidelines