Hyperbaric Oxygen (HBO₂) Therapy

This policy covers systemic hyperbaric oxygen (HBO₂) therapy for specified medical indications listed in Table 1 (including grade‑4 and grade‑5 diabetic foot gangrene and certain reconstructive services for trauma) and, in Illinois only, therapy for pediatric patients with specific clinical or genetic diagnoses causing low‑tone neuromuscular, neurological, or cognitive impairment. Coverage is limited to specified fully insured Illinois plan types effective for policies amended/issued/renewed on or after 2025‑01‑01, excludes topical HBO₂ as experimental, caps initial treatment numbers with documentation required for extensions, and excludes many indications (e.g., acute MI, organ transplantation, osteoarthritis, sports‑related muscle soreness).

"Medically necessary reconstructive services intended to restore physical appearance of body structures damaged by trauma."