Coverage of Conditions and Treatments (Coverage Decisions)

Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.

List also available in PDF format.

See Treatment Guidelines and Resources for additional information.

HBOT involves the therapeutic administration of 100% oxygen at environmental pressures > 1 atmosphere absolute (ATA), the atmospheric pressure at sea level. Administering oxygen at pressures greater than 1 ATA requires compression. This is achieved by placing the patient in an airtight chamber. The pressure is increased inside the chamber, and 100% oxygen is given for respiration, which delivers a greatly increased pressure of oxygen to the lungs, blood, and tissues.

This coverage decision concerns the use of HBOT for tissue damage only. Therapy is usually provided for one to two hours under hyperbaric conditions, and patients typically require 10 to 60 therapy sessions. It is delivered in single person or multiple person chambers.

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.

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: 
What we're working on | Washington State Health Care Authority

Implementation of the Determination

All requests for HBOT require prior authorization.