Selasa, 15 Mei 2012

Hyperbaric Oxygen Therapy (HBOT)

 Fallon Community Health Plan

Effective date:
Revision date(s):
Hyperbaric Oxygen Therapy (HBOT)
09/2000, 01/2001, 11/17/2003
Important note
Even though this policy may indicate that a particular service or supply is considered covered, this conclusion is
not based upon the terms of your particular benefit plan. Each benefit plan contains its own specific provisions for
coverage and exclusions. Not all benefits that are determined to be medically necessary will be covered benefits
under the terms of your benefit plan. You need to consult the Evidence of Coverage to determine if there are any
exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between this
policy and your plan of benefits, the provisions of your benefits plan will govern. However, applicable state
mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government,
school boards, church) plans. Unless otherwise specifically excluded, federal mandates will apply to all plans. With
respect to Medicare and Medicaid members, this policy will apply unless Medicare and Medicaid policies extend
coverage beyond this Medical Policy and Criteria Statement. Medicare and Medicaid policies will only apply to
benefits paid for under Medicare or Medicaid rules, and not to any other health benefit plan benefits. The Centers
for Medicare and Medicaid’s Coverage Issues Manual can be found on the following Web site:
Hyperbaric oxygen therapy (HBOT or hyperbaric O2) is a technique of delivering higher pressures of oxygen to
the tissues. The two methods of administration are in a large chamber or via a mask, head tent or endotracheal tube.
In systemic or large chamber hyperbaric oxygen, the patient is entirely enclosed in a pressure chamber and breathes
oxygen at a pressure greater than one atmosphere (the pressure of O2 at sea level). This technique relies on the
patient’s systemic circulation to deliver highly oxygenated blood to the target site, usually a wound. HBOT can also
be used to treat systemic illness, such as air or gas embolism, carbon monoxide poisoning and clostridial gas
Policy and criteria
NOTE: These services require prior authorization by the plan medical director.
When services are covered:
We cover HBOT as treatment for ANY of the following conditions:
   Acute carbon monoxide intoxication
   Decompression illness
   Gas embolism
   Gas gangrene
   Acute traumatic peripheral ischemia. HBOT is a valuable adjunctive treatment to be used in combination
       with accepted standard therapeutic measures when loss of function, limb, or life is threatened.
   Crush injuries and suturing of severed limbs. As in the previous conditions, HBOT would be an adjunctive
       treatment when loss of function, limb, or life is threatened.
   Progressive necrotizing infections (necrotizing fasciitis)
   Acute peripheral arterial insufficiency
   Preparation and preservation of compromised skin grafts (not for primary management of wounds)
   Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management
Hyperbaric Oxygen Therapy (HBOT)
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Osteoradionecrosis as an adjunct to conventional treatment
Soft tissue radionecrosis as an adjunct to conventional treatment
Cyanide poisoning
Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to
antibiotics and surgical treatment
Diabetic wounds of the lower extremities in patients who meet the following three criteria:
     1. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes.
     2. Patient has a wound classified as Wagner grade III or higher.
     3. Patient has failed an adequate course of standard wound therapy.
NOTE: The use of HBOT 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, and 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 HBOT.
Continued treatment with HBOT is not covered if measurable signs of healing have not been demonstrated
within any 30-day period of treatment.
When services are not covered:
We do not cover services when the above criteria are not met or for any procedures or devices not listed above.
We do not cover topical (or partial) hyperbaric oxygen therapy or topical oxygen therapy. Topical HBOT is
therapy administered to the open wound in small limb-encasing devices. This method is considered investigational,
as its efficacy has not been established through controlled clinical trials.
We do not cover HBOT in any of the following conditions, as it is considered experimental and investigational due
to insufficient evidence in the medical literature establishing HBOT as being more effective than conventional
                                                                Ophthalmologic diseases (including diabetic
                                                                  retinopathy, retinal detachment, central retinal arteryAcute cerebral edema
                                                                  occlusion, radiation injury to the optic nerve)Intracranial abscesses
 Acute or chronic cerebral vascular insufficiency
 Lepromatous leprosy
 Acute renal arterial insufficiency
 Lyme disease
 Acute thermal and chemical pulmonary damage, i.e.,
    smoke inhalation with pulmonary insufficiency
 Aerobic septicemia
 Multiple Sclerosis
 Anaerobic septicemia and infection other than
 Myocardial infarction
 Anemia due to exceptional blood loss
 Nonvascular causes of chronic brain syndrome
    (Pick’s disease, Alzheimer’s disease, Korsakoff’s
 Arthritic diseases, including rheumatoid arthritis
Hyperbaric Oxygen Therapy (HBOT)
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  Bone grafts or fracture healing
  Organ transplantation and/or storage
  Brown recluse spider bites
  Pulmonary emphysema
  Cardiogenic shock
  Pyoderma gangrenosum
  Cerebral palsy
  Radiation-induced cystitis, myelitis, enteritis, or
Chronic peripheral vascular insufficiency
  Cutaneous, decubitus, and stasis ulcers
  Severe or refractory perineal Crohn’s disease
  Headaches, including migraine or cluster
  Sickle cell anemia
  Hepatic necrosis
  Skin burns (thermal)
  Intra-abdominal abscess, pseudomembranous colitis
  (antibiotic-induced colitis)
Systemic aerobic infection
                                Physician attendance and supervision of hyperbaric oxygen therapy, per
Copyright © 2003 American Medical Association, Chicago, IL
FCHP products to which this policy applies:
FCHP Direct and FCHP Select Care (HMO)
FCHP Flex Care Direct and Select (POS)
Fallon Preferred Care (PPO)
FCHP MassHealth
Non-Group: FCHP Independent Care, Direct enrollment and Bill-at-home
Medicare plan – reminder to refer to CMS for policy and criteria
Bello YM, Phillips TJ. Recent advances in wound healing. JAMA. 2000;283:716-718.
Bevers RF, Bakker DJ, Kurth KH. Hyperbaric oxygen treatment for haemorrhagic radiation cystitis. Lancet.
Bozzuto TM, Fife CE, Graham WP, Bello YM, Phillips TJ. Letters: Adjunctive Therapies for Wound Healing. JAMA.
Caplan ES. Hyperbaric oxygen. Pediatr Infect Dis J. 2000;19(2):151-152.
Centers for Medicare & Medicaid Services. Decision Memorandum. Hyperbaric Oxygen Therapy for Hypoxic Wounds and
Diabetic Wounds of the Lower Extremities (#CAG-00060N). August 30, 2002.
Centers for Medicare & Medicaid Services. National Coverage Determination. Hyperbaric Oxygen Therapy. Coverage
Issues Manual §35-10. Baltimore, MD: April 1, 2003.
Collet JP, Vanasse M, Marois P, et al. Hyperbaric oxygen for children with cerebral palsy: a randomized multicentre trial.
Lancet 2001; 357: 582-586.
Davis TR, Griffiths ID, Stevens J. Hyperbaric oxygen treatment for rheumatoid arthritis; failure to show worthwhile benefit.
Br J Rheumatol. 1988;27(1):72.
Del Pizzo JJ, Chew BH, Jacobs SC, et al. Treatment of radiation induced hemorrhagic cystitis with hyperbaric oxygen:
Long-term followup. J Urol. 1998;160(3 Pt 1):731-733.
Denton AS, Andreyev HJ, Forbes A, Maher EJ. Systematic review for non-surgical interventions for the management of late
radiation proctitis. Br J Cancer. 2002;87(2):134-143.
Edsberg LE, Brogan MS, Jaynes CD, Fries K. Topical hyperbaric oxygen and electrical stimulation: Exploring potential
synergy. Ostomy Wound Manage. 2002;48(11):42-50.
Ennis RD. Hyperbaric oxygen for the treatment of radiation cystitis and proctitis. Curr Urol Rep. 2002;3(3):229-231.
Faglia E, Favales F, Aldeghi A, et al. Adjunctive systemic hyperbaric oxygen therapy in treatment of severe prevalently
ischemic diabetic foot ulcer: A randomized study. Diabetes Care.1996;19(12):1338-1343.
Hyperbaric Oxygen Therapy (HBOT)
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14. Hammarlund C, Sundberg T. Hyperbaric oxygen reduced size of chronic leg ulcers: A randomized double-blind study. Plast
    Reconstr Surg 1994; 93: 829-833.
15. Hayes, Winifred S. Technology Assessment Reports:
Hyperbaric Oxygen Therapy for Burns, Infections, and Wounds. May 2002; Updated 6/18/03.
Hyperbaric Oxygen Therapy for Carbon Monoxide Poisoning. October 2003.
Topical Oxygen Therapy for Chronic Wound Healing. January 2002; Updated 5/13/03.
16. Heng MCY, Harker J, Csathy G, et al. Angiogenesis in necrotic ulcers treated with hyperbaric oxygen. Osotomy/Wound
    Management 2000; 46(9): 18-32.
17. Heng MCY. Topical hyperbaric therapy for problem skin wounds. J Dermatol Surg Oncol 1993; 19: 784-93.
18. Kalliainen LK, Gordillo GM, Schlanger R. Topical oxygen as an adjunct to wound healing: a clinical case series.
    Pathophysiology 2003; 9: 81-87.
19. Lamm K, Lamm H, Arnold W. Effect of hyperbaric oxygen therapy in comparison to conventional or placebo therapy or no
    treatment in idiopathic sudden hearing loss, acoustic trauma, noise-induced hearing loss and tinnitus. A literature survey.
    Adv Otorhinolaryngol. 1998;54:86-99.
20. Landau Z, Schattner A. Topical hyperbaric oxygen and low level energy laser therapy for chronic diabetic foot ulcers
    resistant to conventional treatment. Yale J Biol Med 2001; 74(2): 95-100.
21. Landau Z. Topical hyperbaric oxygen and low energy laser for the treatment of diabetic foot ulcers. Arch Orthop Trauma
    Surg 1998; 117: 156-8.
22. Leach RM, Rees PJ, Wilmshurst P. Hyperbaric oxygen therapy. Br Med J. 1998;317:1140-1143.
23. Leslie CA, Sapico FL, Ginunas VJ, Adkins RH. Randomized controlled trial of topical hyperbaric oxygen for treatment of
    diabetic foot ulcers. Diabetes Care 1988; 11: 111-15.
24. Mathews R, Rajan N, Josefson L, et al. Hyperbaric oxygen therapy for radiation induced hemorrhagic cystitis. J Urol.
25. Mitton C, Hailey D. Health technology assessment and policy decisions on hyperbaric oxygen treatment. Int J Technol
    Assess Health Care. 1999;15(4):661-670.
26. Paw HG, Reed PN. Pneumatosis cystoides intestinalis confined to the small intestine treated with hyperbaric oxygen.
    Undersea Hyperb Med. 1996;23(2):115-117.
27. Pritchard J, Anand P, Broome J, et al. Double blind randomized phase II study of hyperbaric oxygen in patients with
    radiation-induced brachial plexopathy. Radiother & Onc 2001; 58: 279-286.
28. Remahl N, Ansjon R, Lind F et al. Hyperbaric oxygen treatment of active cluster headache: a double-blind placebo-
    controlled cross-over study. Cephalgia 2002; 22: 730-739.
29. Rijkmans BG, Bakker DJ, Dabhoiwala NF, et al. Successful treatment of radiation cystitis with hyperbaric oxygen. Eur
    Urol. 1989;16(5):354-356.
30. Rusyniak DE, Kirk MA, May JD et al. Hyperbaric oxygen therapy in acute ischemic stroke: Results of the Hyperbaric
    Oxygen in Acute Ischemic Stroke Trial Pilot Study. Stroke 2003; 34: 571-574.
31. Saunders P. Hyperbaric oxygen therapy in the management of carbon monoxide poisoning, osteoradionecrosis, burns, skin
    grafts and crush injury. West Midlands Development and Evaluation Service Report. Birmingham, UK: University of
    Birmingham, April 2000.
32. Shank ES, Muth CM. Decompression illness, iatrogenic gas embolism, and carbon monoxide poisoning: the role of
    hyperbaric oxygen therapy. Int Anesthesiol Clin. 2000;38(1):111-138.
33. Sheridan RL, Shank ES. Hyperbaric oxygen treatment: A brief overview of a controversial topic. J Trauma. 1999;47(2):426-
34. Stone JA, Cianci P. The adjunctive role of hyperbaric oxygen therapy in the treatment of lower extremity wounds in patients
    with diabetes. Diabetes Spectrum. 1997;10(2):118-123.
35. The Undersea and Hyperbaric Medical Society, Hyperbaric Oxygen Therapy Committee. Guidelines: Indications for
    Hyperbaric Oxygen. Kensington, MD: UHMS, 2000.
36. The Undersea and Hyperbaric Medical Society, Position Paper. Hyperbaric Oxygen for Chronic Brain Injury. Kensington,
    MD: UHMS, 2003.
37. The Undersea and Hyperbaric Medical Society, Position Paper. The Treatment of Multiple Sclerosis with Hyperbaric
    Oxygen Therapy. Kensington, MD: UHMS, 2000.
38. Tibbles PM, Edelsberg JS. Hyperbaric oxygen therapy. N Engl J Med. 1996;334(25):1642-1648.
Hyperbaric Oxygen Therapy (HBOT)
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di tayangkan ulang oleh dr.Erick Supondha (hyperbaric&Diving medicine Consultant) Jakarta Indonesia 021 99070050 ,http//

39. U.S. Department of Health and Human Services, Public Health Service. Hyperbaric oxygen therapy for treatment of soft
     tissue radionecrosis and osteoradionecrosis. Health Technology Assessment Reports. DHHS Publication No. (PHS)
     84.3371. Washington, DC: DHHS, 1982.
40. Wang C, Lau J. Hyperbaric oxygen therapy in treatment of hypoxic wounds. Agency for Healthcare Research and Quality
     Contract No. 270-97-0019. Boston, MA: New England Medical Center Evidence-Based Practice Center; November 2, 2001.
41. Wang J, Li F, Calhoun JH, Mader JT. The role and effectiveness of adjunctive hyperbaric oxygen therapy in the
     management of musculoskeletal disorders. J Postgrad Med. 2002;48(3):226-231.
42. Weaver LK, Hopkins RO, Chan KJ, et al. Hyperbaric oxygen for acute carbon monoxide poisoning. N Engl J Med.
43. Weiss JP, Mattei DM, Neville EC, et al. Primary treatment of radiation-induced hemorrhagic cystitis with hyperbaric
     oxygen: 10-year experience. J Urol. 1994;151(6):1514-1517.
44. Zamboni WA, Wong HP, Stephenson T, et al. Evaluation of hyperbaric oxygen for diabetic wounds: A prospective study.
     Undersea Hyperbar Med. 1997;24(3):175-179.
Mandated benefit/Regulatory issues
Commonwealth of Massachusetts
Medicare – National policy
Medicare – Local medical review policy
Not applicable
Committee review dates:
Technology Assessment Committee: 09/2000; 01/2001; mm/yyyy
Utilization Management Committee: 06/2003
Approved by:Signature on file
Dennis A. Batey, M.D., Vice President and Chief Medical Officer
Hyperbaric Oxygen Therapy (HBOT)
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di tayangkan ulang oleh dr.Erick Supondha (hyperbaric&Diving medicine Consultant) Jakarta Indonesia 021 99070050 ,http//