Topical Oxygen Therapy (TOT) Devices - DME.SW.107.A

Topical oxygen therapy devices (HCPCS A4575, E0446) are covered only as an adjunct for non‑healing Wagner Grade 1–2 diabetic foot ulcers and are excluded for wounds with untreated osteomyelitis, necrotic slough/eschar, fistulae/deep sinus tracts, cancer in the wound, exposed nerves/vascular structures, or other Wagner grades/etiologies. Coverage requires prior standard wound care (assessment/measurements, appropriate dressings, debridement if needed, infection/underlying‑condition treatment, diabetes care, off‑loading tried, and radiographs), an initial one‑month rental with monthly documentation of wound progress, measurements and proper device use for continued rental, and additional detailed monthly justification if use extends beyond three months.

"Debridement has been performed to remove necrotic tissue (if present)."

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