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National Coverage Determination (NCD)

Hyperbaric Oxygen Therapy

35-10

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Tracking Information

Publication Number
6
Manual Section Number
35-10
Manual Section Title
Hyperbaric Oxygen Therapy
Version Number
1
Effective Date of this Version
10/19/2000
Ending Effective Date of this Version
04/01/2003
Implementation Date
Implementation QR Modifier Date

Description Information

Benefit Category
Incident to a physician's professional Service
Outpatient Hospital Services Incident to a Physician's Service
Physicians' Services


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description
Indications and Limitations of Coverage

For purposes of coverage under Medicare, hyperbaric oxygen (HBO) therapy is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure.

  1. Covered Conditions. Program reimbursement for HBO therapy will be limited to that which is administered in a chamber (including the one man unit) and is limited to the following conditions:
    1. Acute carbon monoxide intoxication, (ICD-9-CM diagnosis 986).
    2. Decompression illness, (ICD-9-CM diagnosis 993.2, 993.3).
    3. Gas embolism, (ICD-9-CM diagnosis 958.0, 999.1).
    4. Gas gangrene, (ICD-9-CM diagnosis 0400).
    5. Acute traumatic peripheral ischemia. 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. (ICD-9-CM diagnosis 902.53, 903.01, 903.1, 904.0, 904.41.)
    6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened. (ICD-9-CM diagnosis 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.)
    7. Progressive necrotizing infections (necrotizing fasciitis), (ICD-9-CM diagnosis 728.86).
    8. Acute peripheral arterial insufficiency, (ICD-9-CM diagnosis 444.21, 444.22, 81).
    9. Preparation and preservation of compromised skin grafts (not for primary management of wounds), (ICD-9CM diagnosis 996.52; excludes artificial skin graft).
    10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management, (ICD-9-CM diagnosis 730.10-730.19).
    11. Osteoradionecrosis as an adjunct to conventional treatment, (ICD-9-CM diagnosis 526.89).
    12. Soft tissue radionecrosis as an adjunct to conventional treatment, (ICD-9-CM diagnosis 990).
    13. Cyanide poisoning, (ICD-9-CM diagnosis 987.7, 989.0).
    14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment, (ICD-9-CM diagnosis 039.0-039.4, 039.8, 039.9).

  2. Noncovered Conditions. All other indications not specified under §35-10(A) are not covered under the Medicare program. No program payment may be made for any conditions other than those listed in § 35-10 (A).

    No program payment may be made for HBO in the treatment of the following conditions:

    1. Cutaneous, decubitus, and stasis ulcers.
    2. Chronic peripheral vascular insufficiency.
    3. Anaerobic septicemia and infection other than clostridial.
    4. Skin burns (thermal).
    5. Senility.
    6. Myocardial infarction.
    7. Cardiogenic shock.
    8. Sickle cell anemia.
    9. Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency.
    10. Acute or chronic cerebral vascular insufficiency.
    11. Hepatic necrosis.
    12. Aerobic septicemia.
    13. Nonvascular causes of chronic brain syndrome (Pick’s disease, Alzheimer’s disease, Korsakoff’s disease).
    14. Tetanus.
    15. Systemic aerobic infection.
    16. Organ transplantation.
    17. Organ storage.
    18. Pulmonary emphysema.
    19. Exceptional blood loss anemia.
    20. Multiple Sclerosis.
    21. Arthritic Diseases.
    22. Acute cerebral edema.

  3. Reasonable Utilization Parameters. Make payment where HBO therapy is clinically practical. HBO therapy should not be a replacement for other standard successful therapeutic measures. Depending on the response of the individual patient and the severity of the original problem, treatment may range from less than 1 week to several months duration, the average being 2 to 4 weeks. Review and document the medical necessity for use of hyperbaric oxygen for more than 2 months, regardless of the condition of the patient, before further reimbursement is made.

  4. Topical Application of Oxygen. This method of administering oxygen does not meet the definition of HBO therapy as stated above. Also, its clinical efficacy has not been established. Therefore, no Medicare reimbursement may be made for the topical application of oxygen.
Cross Reference
§35-31
Claims Processing Instructions

Transmittal Information

Transmittal Number
129
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R129CIM.pdf
Revision History

10/2000 - Manualized program memorandum AB-00-15 (dated 4/1/2000) and clarified that "preparation and preservation of compromised skin graft" in section 35-10A.9 is not for primary management of wounds. Effective date NA. (TN 129 ) (CR 1138)

04/1999 - Clarified covered conditions and physician supervision requirement. Effective date 05/01/1999. (TN 112)

07/1997 - Clarified that coverage is limited to conditions listed under §35-10.A. Effective date 08/11/1997. (TN 102)
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Hyperbaric Oxygen Therapy 4 04/03/2017 - N/A View
Hyperbaric Oxygen Therapy 3 06/19/2006 - 04/03/2017 View
Hyperbaric Oxygen Therapy 2 04/01/2003 - 06/19/2006 View
Hyperbaric Oxygen Therapy 1 10/19/2000 - 04/01/2003 You are here
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Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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