G0277 — Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
$193.73
Non-Facility
$193.73
Documentation Required
- There is no discrete "Documentation Requirements" section in the provided policy text; the policy instructs that coverage decisions must reference the member-specific benefit plan document and applicable laws.
- Inferred / Clinically implied documentation (based on policy text, cited guidelines, and evidence summaries) that may be required to support medical necessity for HBOT (examples extracted from guideline statements and evidence in the policy):
- - For acute traumatic peripheral ischemia/crush injury: documentation of injury severity and that tissue viability is threatened; early application (preferably within 4–6 hours) is recommended by UHMS (clinical note indicating timing may be relevant).
- - For air or gas embolism / decompression sickness: clinical diagnosis and timing (onset) consistent with gas embolism or decompression illness.
Key Coverage Criteria
- Acute traumatic peripheral ischemia/insufficiency (i.e., crush injury, reattachment of severed limbs, compartment syndrome)
- Air or gas embolism
- Anemia, severe, when transfusion is refused, delayed, or unavailable
- Avascular necrosis (aseptic osteonecrosis)
- Carbon monoxide poisoning
- Central retinal artery occlusion
12 Active Policies
CIGNA-0053 — Hyperbaric and Topical Oxygen Therapies - (0053)
CIGNA-0447 — Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment - (0447)
AETNA-CPB-0302 — Xerostomia: Selected Treatments
AETNA-CPB-0327 — Infertility
AETNA-CPB-0389 — Hypertrophic Scars and Keloids
Related Codes
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