CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)

This policy addresses hyperbaric oxygen therapy (HBOT), distinguishing systemic pressurization from topical and limb-specific approaches. Systemic HBOT is covered when performed in accordance with Undersea and Hyperbaric Medical Society (UHMS) guidelines for acute peripheral arterial insufficiency, deep second- or third-degree thermal burns, acute traumatic ischemia, and carbon monoxide poisoning. Topical and limb-specific HBOT are not medically necessary in all cases, and systemic HBOT is not covered for other indications, including osteonecrosis of the jaw not due to radiation necrosis and preoperative treatment for jaw osteomyelitis.

"Systemic hyperbaric oxygen pressurization is consideredmedically necessaryin the treatment of any of the following conditions when performed in accordance with Undersea and Hyperbaric Medical Socie..."

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