Fallon Community Health Plan
Subject:
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Number:
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Effective date:
Revision date(s):
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Hyperbaric
Oxygen Therapy (HBOT)
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200311-0003
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11/24/2003
09/2000, 01/2001, 11/17/2003
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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:
http://www.cms.hhs.gov/manuals/pub06pdf/pub06pdf.asp.
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Overview
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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
gangrene.
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Policy and criteria
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NOTE: These services require prior authorization by the plan medical director.
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When services
are covered:
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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
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Hyperbaric Oxygen Therapy (HBOT)
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Page 1 of 5
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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.
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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.
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When services
are not covered:
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We do not cover services
when the above criteria are not met or for any procedures or devices not listed
above.
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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.
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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
therapies:
• Ophthalmologic diseases
(including diabetic
retinopathy, retinal detachment, central retinal artery• Acute 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
• Meningitis
• Aerobic septicemia
• Multiple Sclerosis
• Anaerobic septicemia and
infection other than
clostridial
• Myocardial infarction
• Anemia due to exceptional
blood loss
• Nonvascular causes of
chronic brain syndrome
(Pick’s
disease, Alzheimer’s disease, Korsakoff’s
disease)
• Arthritic diseases, including
rheumatoid arthritis
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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
proctitis
• Chronic peripheral vascular
insufficiency
• Senility
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Codes:
Codes
CPT
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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
• Tetanus
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Description
Physician attendance and supervision of hyperbaric
oxygen therapy, per
session
Copyright © 2003 American Medical Association,
Chicago, IL
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FCHP products to which this policy applies:
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⊕
⊕
⊕
⊕
⊕
⊕
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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
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Number
99183
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References
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1.
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3.
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4.
5.
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6.
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7.
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8.
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9.
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10.
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11.
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12.
13.
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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.
1995;346(8978):803-805.
Bozzuto TM, Fife CE, Graham WP, Bello YM, Phillips
TJ. Letters: Adjunctive Therapies for Wound Healing. JAMA.
2000;284:40-41.
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.
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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.
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Page 3 of 5
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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:
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Hyperbaric Oxygen Therapy for Burns, Infections,
and Wounds. May 2002; Updated 6/18/03.
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Hyperbaric Oxygen Therapy for Carbon Monoxide
Poisoning. October 2003.
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Topical Oxygen Therapy for Chronic Wound Healing.
January 2002; Updated 5/13/03.
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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.
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17. Heng MCY. Topical hyperbaric therapy for
problem skin wounds. J Dermatol Surg Oncol 1993; 19: 784-93.
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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.
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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.
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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.
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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.
1999;161(2):435-437.
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.
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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.
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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.
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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-
435.
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.
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Hyperbaric Oxygen Therapy (HBOT)
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Page 4 of 5
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di
tayangkan ulang oleh dr.Erick Supondha (hyperbaric&Diving medicine
Consultant) Jakarta Indonesia 021 99070050
,http//:wwwindodivinghealth.com
tissue radionecrosis and osteoradionecrosis. Health Technology Assessment
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84.3371. Washington, DC: DHHS, 1982.
40. Wang C, Lau J. Hyperbaric oxygen therapy
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41. Wang J, Li F, Calhoun JH, Mader JT. The
role and effectiveness of adjunctive hyperbaric oxygen therapy in the
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42. Weaver LK, Hopkins RO, Chan KJ, et al. Hyperbaric oxygen for acute
carbon monoxide poisoning. N Engl J Med.
2002;347(14):1057-1067.
43. Weiss JP, Mattei DM, Neville EC, et al.
Primary treatment of radiation-induced hemorrhagic cystitis with hyperbaric
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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.
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Mandated benefit/Regulatory issues
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∅ Federal
∅ Commonwealth of Massachusetts
⊕ Medicare – National policy
∅ Medicare – Local medical review policy
∅ Not applicable
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Committee review dates:
Technology Assessment Committee: 09/2000; 01/2001; mm/yyyy
Utilization Management Committee: 06/2003
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Approved by:Signature on file
Dennis A. Batey, M.D., Vice President and Chief
Medical Officer
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11/20/2003
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Date
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Hyperbaric Oxygen Therapy (HBOT)
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Page 5 of 5
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di
tayangkan ulang oleh dr.Erick Supondha (hyperbaric&Diving medicine
Consultant) Jakarta Indonesia 021 99070050
,http//:wwwindodivinghealth.com
