Hyperbaric Oxygen Therapy (HBOT)

Coverage decision: Covered with conditions

To receive the benefit, injured workers must have the primary condition that is accepted on the claim, and have at least one of the following conditions:

  • Crush injuries and suturing of severed limbs; as an adjunct when loss of function, limb, or life is threatened.
  • Compromised skin grafts and flaps (not for primary management of wounds).
  • Chronic refractory osteomyelitis unresponsive to conventional medical and surgical management.
  • Osteoradionecrosis; as an adjunct to conventional treatment.
  • For prevention of osteoradionecrosis associated with tooth extraction in a radiated field.
  • Soft tissue radionecrosis; as an adjunct to conventional treatment.
  • Diabetic wounds in patients who meet the following three criteria:
    • Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
    • Patient has a wound classified as Wagner grade III or higher; and
    • Patient has failed an adequate course of standard wound therapy.

HBOT is not covered for the following conditions:

  • Brain injury including traumatic (TBI) and chronic brain injury
  • Cerebral Palsy
  • Multiple Sclerosis
  • Migraine or cluster headaches
  • Acute and chronic sensorineural hearing loss
  • Thermal burns
  • Non-healing venous, arterial and pressure ulcers

Criterion for Continuing Treatment beyond 30 sessions

In order for payment for HBOT to continue beyond 30 sessions, licensed medical personnel must provide documentation of wound measurements that demonstrate clinically meaningful improvement has occurred with the first 30 sessions.  The maximal treatment sessions allowed are 60.

Note: The insurer typically pays for HBOT for the following conditions resulting from a work-related incident: air or gas embolism, carbon monoxide poisoning and decompression sickness.

Background Policy Information

The State Health Technology Clinical Committee (HTCC) reviewed HBOT on March 22, 2013. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that HBOT is covered benefits with conditions.  Complete information on this HTCC determination is available here:
http://www.hca.wa.gov/hta/Pages/Hyperbaric%20Oxygen%20(HBO2)%20Treatment%20for%20Tissue%20Damage.aspx

Implementation of the Determination

All requests for HBOT require prior authorization.

For State Fund Claims

All requests will be reviewed by L&I’s occupational nurse consultant and claims manager.

  • Complete the Preauthorization Form and fax to:(360) 902-4567
  • For additional information contact the claims manager
    • To obtain the claims manager’s phone number call 1-800-831-5227
    • Attending physician, concurrent care provider or IME log into the Claims & Account Center (CAC)
For Self-Insured Claims

Please contact the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIE/TPAs, go to:
http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp

Billing Codes

CPT ® Code: 99183
HCPCS Code: C1300

Health Care Authority's Health Technology Assessment Program site

For more information:
Contact information.

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