Aetna Hyperbaric Oxygen Therapy (HBOT) coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Systemic HBOT is medically necessary for ANY of the listed conditions (covered indications follow); HBOT should not replace other standard successful therapeutic measures.
• Acute air or gas embolism (up to 10 sessions).
• Acute carbon monoxide poisoning (1 to 3 sessions or to clinical plateau).
• Acute peripheral arterial insufficiency requiring emergent surgical intervention (e.g., surgical or catheter-directed embolectomy or bypass surgery), WITH imaging documentation of embolus/thrombus (e.g., MR, angiogram) (three treatments in the first 24 hours then twice daily until tissue at risk subsides).
• Acute thermal burns (twice daily for up to 30 sessions).
• Acute traumatic ischemia (including crush injuries and suturing of severed limbs) when loss of function, limb, or life is threatened AND HBOT is used in combination with standard therapy (twice a day up to 7 days or 14 sessions); HBOT should be started as close as possible to the time of injury.
• Avascular necrosis - treatment schemes vary by disease stage per Ficat classification for the Femoral Head: Ficat stage 1 (goal full healing): 30 to 40 treatments (1/day for 60-70 min); Ficat stage II (goal lesional resolution): 30 to 40 treatments (1/day for 60-70 min) followed by a 20-30 day pause then another 20 treatments, followed by MRI and orthopedic evaluation at one month; Ficat stage IIIA or worse: same regimen as stage II, repeatable (once or twice) at four to six months from the MRI/orthopedic assessment (cost/benefit of delaying surgery weighed against urgency/feasibility of prosthesis placement).
• Central retinal artery occlusion (CRAO), acute treatment (treat twice daily until clinical plateau, typically less than a week, plus three days; usual medically necessary duration up to 10 days).
• Chronic refractory stage 3 or 4 osteomyelitis confirmed by radiological diagnosis (X-ray or MRI) OR a bone culture, which has been unresponsive to conventional medical AND surgical management, including a six-week course of parenteral antibiotics or alternative oral antibiotic regimen if indicated (e.g., amoxicillin-clavulanate, clindamycin, fluoroquinolones, linezolid, tetracyclines, trimethoprim-sulfamethoxazole plus rifampin) AND at least one surgical eradication/debridement attempt, UNLESS contraindicated; if wounds present, must be evaluated with photographic documentation (with ruler) after every 15 treatments and/or at least every 30 days; continued HBOT not medically necessary if no measurable signs of healing within any 30-day period (up to 40 sessions). NOTE: chronic refractory osteomyelitis can occur with or without a wound and does not always require an open wound to be treated; HBOT is beneficial particularly when refractory to antibiotics and surgical debridement and when complicated by adverse local or systemic factors.
• Compartment syndrome (twice a day for 2 to 7 days).
• Compromised skin grafts and flaps where hypoxia or decreased perfusion has compromised viability acutely (NOT for maintenance of split-thickness skin grafts or artificial skin substitutes); for lower extremity wounds graft/flap must be evaluated with photographic documentation (with ruler) after every 20 treatments or 30 days; continued HBOT not medically necessary if no measurable signs of healing within any 30-day period (twice daily up to 20 sessions).
• Cyanide poisoning, frequently present with simultaneous carbon monoxide poisoning (1 to 3 sessions or to clinical plateau).
• Decompression sickness ('the bends') (1 session up to a clinical plateau; typically no more than 1 to 2 treatment sessions needed).
• Diabetic lower extremity wounds, selected individuals: non-healing infected deep ulcerations (reaching tendons or bone) (Wagner grade 3 or more) of the lower extremity, with photographic (with ruler) documentation, in diabetic adults unresponsive to at least 1 month of meticulous wound care. Standard wound care must include ALL of: assessment of vascular status and correction of vascular problems in the affected limb if possible; optimization of nutritional status; optimization of glucose control; debridement by any means to remove devitalized tissue; maintenance of clean moist bed of granulation tissue with appropriate moist dressings; appropriate off-loading; necessary treatment to resolve any infection present. Failure to respond = no measurable signs of healing for at least 30 consecutive days; wounds evaluated at least every 30 days during HBOT; continued HBOT not medically necessary if no measurable signs of healing within any 30-day period; usual duration up to 40 sessions, and for continuation the wound must show healing progress, no more than 60 sessions usually considered medically necessary.
• Gas gangrene (clostridial myositis and clostridial myonecrosis) (three times in the first 24 hours, then twice daily for the next 2 to 5 days).
• Idiopathic sudden sensorineural hearing loss (SSHL) - SSHL greater than 30 dB affecting greater than 3 consecutive frequencies of pure-tone thresholds, when member has FAILED oral AND intra-tympanic steroids, AND HBOT is initiated within 3 months after onset (up to 20 sessions).
• Intracranial abscess (includes cerebral abscess, subdural empyema, and epidural empyema) (1 to 2 times a day for up to 3 weeks; up to 15 sessions).
• Pneumatosis cystoides intestinalis (daily 2.5 hour treatments for up to 3 days).
• Progressive necrotizing soft tissue infections, including mixed aerobic and anaerobic infections (Meleney's ulcer, necrotizing fasciitis), with history of inpatient treatment including antibiotics AND surgical debridement (unless contraindicated) AND (where appropriate) full-thickness or split-thickness skin grafts, with photographic documentation (with ruler) of the wound if present; wounds evaluated with photographic documentation (with ruler) after every 15 treatments and/or at least every 30 days; continued HBOT not medically necessary if no measurable signs of healing within any 30-day period (twice daily until stabilization; usual duration up to 30 sessions).
• Prophylaxis and treatment of radiation necrosis of the mandible in members undergoing dental surgery of a radiated jaw, where the extraction site is anticipated to be within the XRT portal, AND where HBOT is delivered according to established (Marx) protocol, with 20 HBOT treatments prior to surgery and 10 HBOT treatments immediately after surgery.
• Radiation-induced hemorrhagic cystitis (daily 90-minute treatments, up to 40 sessions).
• Radiation-induced necrosis (including brain radionecrosis, myoradionecrosis, osteoradionecrosis (including jaw osteonecrosis), and other soft tissue radiation necrosis including breast, chest wall, head and neck, and pelvic organs (e.g., bladder and rectum)) (typically up to 40 HBOT treatments medically necessary, plus an additional 10 treatments to support tissues after surgical reconstruction if performed).
• Radiation proctitis (up to 45 sessions).
• Severe blood loss anemia ONLY when there is overwhelming blood loss AND transfusion is impossible because no suitable blood is available OR religion does not permit transfusions (three or four times a day until replacement of red blood cells by regeneration or transfusion).
• Continuation of therapy: HBOT is NOT medically necessary if measurable signs of healing have not been demonstrated within any 30-day period of treatment. Signs of healing examples (not exhaustive): WOUNDS - evaluated with photographic documentation including a ruler after every 15 treatments and/or at least every 30 days with measurable signs of healing (granulation, epithelialization, or progress toward closing); CHRONIC OSTEOMYELITIS - reduced pain, decreased swelling, improved wound healing (if wound present), decreased inflammatory markers (e.g., ESR, CRP), radiographic evidence of bone healing, reduced infection symptoms; COMPROMISED FLAPS - close clinical observation (e.g., warm pink color), non-invasive vascular studies (e.g., transcutaneous oximetry Tcom/TcpO2 where <40 mmHg suggests continued compromise and rising values >40-50 mmHg demonstrate improved oxygenation; laser dopplers or Indocyanine Green Angiography ICGA), and assessment of wound healing progression; RADIATION-INDUCED CYSTITIS - reduction of symptoms (hematuria, pain, urinary frequency), improved Hgb/Hct, decreased blood transfusions, improved quality of life; RADIATION-INDUCED PROCTITIS - reduced rectal bleeding, decreased pain, improved bowel function, and/or endoscopic evidence of healed tissue.
• General duration guidance: treatment may range from less than 1 week to several months, average 2 to 4 weeks; HBOT for more than 2 months is usually not necessary.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 99183·PA verdict·Rate
• G0277·PA verdict·Rate

Documentation required

• For wounds generally: evaluation with photographic documentation INCLUDING A RULER after every 15 treatments and/or at least every 30 days during administration of HBOT, showing measurable signs of healing (granulation, epithelialization, or progress toward closing).
• Compromised skin grafts and flaps: photograph (with ruler) of graft or flap, type of flap, name of surgeon performing the graft or flap, and whether there was surgical exploration; for lower extremity wounds, graft/flap evaluated with photographic documentation (with ruler) after every 20 treatments or 30 days.
• Chronic refractory osteomyelitis: radiological diagnosis (X-ray or MRI) OR bone culture confirmation; if wounds present, photographic documentation (with ruler) after every 15 treatments and/or at least every 30 days.
• Diabetic lower extremity wounds: photographic (with ruler) documentation; wounds evaluated at least every 30 days during HBOT.
• Progressive necrotizing soft tissue infections: photographic documentation (with ruler) of the wound if present; wounds evaluated with photographic documentation (with ruler) after every 15 treatments and/or at least every 30 days.
• Acute peripheral arterial insufficiency: imaging documentation of embolus/thrombus (e.g., MR, angiogram).
• Idiopathic sudden sensorineural hearing loss: documentation of pure-tone thresholds (>30 dB affecting >3 consecutive frequencies).

Frequently asked questions

When does Aetna cover Hyperbaric Oxygen Therapy (HBOT) (CPT 99183), and what gets it denied?

Aetna covers systemic hyperbaric oxygen therapy (HBOT) as medically necessary only for a defined list of conditions (e.g., acute air/gas embolism, carbon monoxide and cyanide poisoning, gas gangrene, decompression sickness, acute traumatic ischemia/crush injury, compromised skin grafts/flaps, chronic refractory stage 3-4 osteomyelitis, selected infected deep diabetic lower-extremity wounds, necrotizing soft tissue infections, radiation necrosis/cystitis/proctitis, avascular necrosis by Ficat stage, idiopathic sudden sensorineural hearing loss, and others), each with specific clinical gates, prior failure of standard therapy where applicable, and session limits. For chronic wound and tissue indications the key gate is documented measurable signs of healing within each 30-day period (with photographic ruler documentation), or HBOT is no longer medically necessary. A large list of other conditions is considered experimental/investigational/unproven, and HBOT is contraindicated (and not covered) with concurrent doxorubicin/cisplatin/disulfiram, in premature infants (<37 weeks), or with untreated pneumothorax. Topical/limb-encasing HBOT and vaporous hyperoxia therapy are not established. The bulletin does not state any precertification requirement. Coverage criteria include: Systemic HBOT is medically necessary for ANY of the listed conditions (covered indications follow); HBOT should not replace other standard successful therapeutic measures.; Acute air or gas embolism (up to 10 sessions).; Acute carbon monoxide poisoning (1 to 3 sessions or to clinical plateau).; Acute peripheral arterial insufficiency requiring emergent surgical intervention (e.g., surgical or catheter-directed embolectomy or bypass surgery), WITH imaging documentation of embolus/thrombus (e.g., MR, angiogram) (three treatments in the first 24 hours then twice daily until tissue at risk subsides).; Acute thermal burns (twice daily for up to 30 sessions).; Acute traumatic ischemia (including crush injuries and suturing of severed limbs) when loss of function, limb, or life is threatened AND HBOT is used in combination with standard therapy (twice a day up to 7 days or 14 sessions); HBOT should be started as close as possible to the time of injury.; Avascular necrosis - treatment schemes vary by disease stage per Ficat classification for the Femoral Head: Ficat stage 1 (goal full healing): 30 to 40 treatments (1/day for 60-70 min); Ficat stage II (goal lesional resolution): 30 to 40 treatments (1/day for 60-70 min) followed by a 20-30 day pause then another 20 treatments, followed by MRI and orthopedic evaluation at one month; Ficat stage IIIA or worse: same regimen as stage II, repeatable (once or twice) at four to six months from the MRI/orthopedic assessment (cost/benefit of delaying surgery weighed against urgency/feasibility of prosthesis placement).; Central retinal artery occlusion (CRAO), acute treatment (treat twice daily until clinical plateau, typically less than a week, plus three days; usual medically necessary duration up to 10 days).; Chronic refractory stage 3 or 4 osteomyelitis confirmed by radiological diagnosis (X-ray or MRI) OR a bone culture, which has been unresponsive to conventional medical AND surgical management, including a six-week course of parenteral antibiotics or alternative oral antibiotic regimen if indicated (e.g., amoxicillin-clavulanate, clindamycin, fluoroquinolones, linezolid, tetracyclines, trimethoprim-sulfamethoxazole plus rifampin) AND at least one surgical eradication/debridement attempt, UNLESS contraindicated; if wounds present, must be evaluated with photographic documentation (with ruler) after every 15 treatments and/or at least every 30 days; continued HBOT not medically necessary if no measurable signs of healing within any 30-day period (up to 40 sessions). NOTE: chronic refractory osteomyelitis can occur with or without a wound and does not always require an open wound to be treated; HBOT is beneficial particularly when refractory to antibiotics and surgical debridement and when complicated by adverse local or systemic factors.; Compartment syndrome (twice a day for 2 to 7 days).; Compromised skin grafts and flaps where hypoxia or decreased perfusion has compromised viability acutely (NOT for maintenance of split-thickness skin grafts or artificial skin substitutes); for lower extremity wounds graft/flap must be evaluated with photographic documentation (with ruler) after every 20 treatments or 30 days; continued HBOT not medically necessary if no measurable signs of healing within any 30-day period (twice daily up to 20 sessions).; Cyanide poisoning, frequently present with simultaneous carbon monoxide poisoning (1 to 3 sessions or to clinical plateau).; Decompression sickness ('the bends') (1 session up to a clinical plateau; typically no more than 1 to 2 treatment sessions needed).; Diabetic lower extremity wounds, selected individuals: non-healing infected deep ulcerations (reaching tendons or bone) (Wagner grade 3 or more) of the lower extremity, with photographic (with ruler) documentation, in diabetic adults unresponsive to at least 1 month of meticulous wound care. Standard wound care must include ALL of: assessment of vascular status and correction of vascular problems in the affected limb if possible; optimization of nutritional status; optimization of glucose control; debridement by any means to remove devitalized tissue; maintenance of clean moist bed of granulation tissue with appropriate moist dressings; appropriate off-loading; necessary treatment to resolve any infection present. Failure to respond = no measurable signs of healing for at least 30 consecutive days; wounds evaluated at least every 30 days during HBOT; continued HBOT not medically necessary if no measurable signs of healing within any 30-day period; usual duration up to 40 sessions, and for continuation the wound must show healing progress, no more than 60 sessions usually considered medically necessary.; Gas gangrene (clostridial myositis and clostridial myonecrosis) (three times in the first 24 hours, then twice daily for the next 2 to 5 days).; Idiopathic sudden sensorineural hearing loss (SSHL) - SSHL greater than 30 dB affecting greater than 3 consecutive frequencies of pure-tone thresholds, when member has FAILED oral AND intra-tympanic steroids, AND HBOT is initiated within 3 months after onset (up to 20 sessions).; Intracranial abscess (includes cerebral abscess, subdural empyema, and epidural empyema) (1 to 2 times a day for up to 3 weeks; up to 15 sessions).; Pneumatosis cystoides intestinalis (daily 2.5 hour treatments for up to 3 days).; Progressive necrotizing soft tissue infections, including mixed aerobic and anaerobic infections (Meleney's ulcer, necrotizing fasciitis), with history of inpatient treatment including antibiotics AND surgical debridement (unless contraindicated) AND (where appropriate) full-thickness or split-thickness skin grafts, with photographic documentation (with ruler) of the wound if present; wounds evaluated with photographic documentation (with ruler) after every 15 treatments and/or at least every 30 days; continued HBOT not medically necessary if no measurable signs of healing within any 30-day period (twice daily until stabilization; usual duration up to 30 sessions).; Prophylaxis and treatment of radiation necrosis of the mandible in members undergoing dental surgery of a radiated jaw, where the extraction site is anticipated to be within the XRT portal, AND where HBOT is delivered according to established (Marx) protocol, with 20 HBOT treatments prior to surgery and 10 HBOT treatments immediately after surgery.; Radiation-induced hemorrhagic cystitis (daily 90-minute treatments, up to 40 sessions).; Radiation-induced necrosis (including brain radionecrosis, myoradionecrosis, osteoradionecrosis (including jaw osteonecrosis), and other soft tissue radiation necrosis including breast, chest wall, head and neck, and pelvic organs (e.g., bladder and rectum)) (typically up to 40 HBOT treatments medically necessary, plus an additional 10 treatments to support tissues after surgical reconstruction if performed).; Radiation proctitis (up to 45 sessions).; Severe blood loss anemia ONLY when there is overwhelming blood loss AND transfusion is impossible because no suitable blood is available OR religion does not permit transfusions (three or four times a day until replacement of red blood cells by regeneration or transfusion).; Continuation of therapy: HBOT is NOT medically necessary if measurable signs of healing have not been demonstrated within any 30-day period of treatment. Signs of healing examples (not exhaustive): WOUNDS - evaluated with photographic documentation including a ruler after every 15 treatments and/or at least every 30 days with measurable signs of healing (granulation, epithelialization, or progress toward closing); CHRONIC OSTEOMYELITIS - reduced pain, decreased swelling, improved wound healing (if wound present), decreased inflammatory markers (e.g., ESR, CRP), radiographic evidence of bone healing, reduced infection symptoms; COMPROMISED FLAPS - close clinical observation (e.g., warm pink color), non-invasive vascular studies (e.g., transcutaneous oximetry Tcom/TcpO2 where <40 mmHg suggests continued compromise and rising values >40-50 mmHg demonstrate improved oxygenation; laser dopplers or Indocyanine Green Angiography ICGA), and assessment of wound healing progression; RADIATION-INDUCED CYSTITIS - reduction of symptoms (hematuria, pain, urinary frequency), improved Hgb/Hct, decreased blood transfusions, improved quality of life; RADIATION-INDUCED PROCTITIS - reduced rectal bleeding, decreased pain, improved bowel function, and/or endoscopic evidence of healed tissue.; General duration guidance: treatment may range from less than 1 week to several months, average 2 to 4 weeks; HBOT for more than 2 months is usually not necessary.. Applies to 2 codes: 99183, G0277. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: For wounds generally: evaluation with photographic documentation INCLUDING A RULER after every 15 treatments and/or at least every 30 days during administration of HBOT, showing measurable signs of healing (granulation, epithelialization, or progress toward closing).; Compromised skin grafts and flaps: photograph (with ruler) of graft or flap, type of flap, name of surgeon performing the graft or flap, and whether there was surgical exploration; for lower extremity wounds, graft/flap evaluated with photographic documentation (with ruler) after every 20 treatments or 30 days.; Chronic refractory osteomyelitis: radiological diagnosis (X-ray or MRI) OR bone culture confirmation; if wounds present, photographic documentation (with ruler) after every 15 treatments and/or at least every 30 days.; Diabetic lower extremity wounds: photographic (with ruler) documentation; wounds evaluated at least every 30 days during HBOT.; Progressive necrotizing soft tissue infections: photographic documentation (with ruler) of the wound if present; wounds evaluated with photographic documentation (with ruler) after every 15 treatments and/or at least every 30 days.; Acute peripheral arterial insufficiency: imaging documentation of embolus/thrombus (e.g., MR, angiogram).; Idiopathic sudden sensorineural hearing loss: documentation of pure-tone thresholds (>30 dB affecting >3 consecutive frequencies). Policy exclusions and limitations: Experimental, investigational, or unproven (not an all-inclusive list) due to insufficient evidence that systemic HBOT is more effective than conventional therapies - the following conditions:; Actinic skin damage (E/I/unproven).; Actinomycosis and other mycoses (E/I/unproven).; Acute cerebral edema (E/I/unproven).; Acute coronary syndrome (E/I/unproven).; Acute kidney injury (E/I/unproven).; Acute or chronic cerebrovascular insufficiency/accident (including thrombotic or embolic stroke) (E/I/unproven).; Acute renal arterial insufficiency (E/I/unproven).; Acute thermal and chemical pulmonary damage, i.e., smoke inhalation (e.g., carbon tetrachloride, hydrogen sulfide) with pulmonary insufficiency (E/I/unproven).; Adhesions prevention after laparotomy (E/I/unproven).; Aerobic septicemia and systemic aerobic infection (E/I/unproven).; Alzheimer's disease (E/I/unproven).; Anaerobic septicemia and infection other than clostridial (E/I/unproven).; Anoxic brain injury (E/I/unproven).; Anti-phospholipid antibody syndrome (E/I/unproven).; Arthritic diseases (E/I/unproven).; Arthritis (E/I/unproven).; Asthma (E/I/unproven).; Autism spectrum disorders (E/I/unproven).; Bacterial keratitis (E/I/unproven).; Bell's palsy (E/I/unproven).; Bone grafts or fracture healing (e.g., nonunion fractures) / bone reconstruction (E/I/unproven).; Brain tumors (E/I/unproven).; Calciphylaxis (calcific uremic arteriolopathy) (E/I/unproven).; Cancer (E/I/unproven).; Cardiogenic shock (E/I/unproven).; Central airway stenosis following lung transplantation (E/I/unproven).; Cerebral palsy (E/I/unproven).; Chemotherapy induced hemorrhagic cystitis (E/I/unproven).; Chronic bowel dysfunction after pelvic radiotherapy (E/I/unproven).; Chronic pain (e.g., cluster headaches, complex regional pain syndrome/reflex sympathetic dystrophy, fibromyalgia, migraines, myofascial pain syndrome, and trigeminal neuralgia) (E/I/unproven).; Chronic peripheral vascular insufficiency (E/I/unproven).; Closed head and/or spinal cord injury (E/I/unproven).; Cognitive impairment (e.g., senility, senile dementia) (E/I/unproven).; Coronary artery disease (E/I/unproven).; COVID-19 (E/I/unproven).; Critical limb ischemia (E/I/unproven).; Cystic acne (E/I/unproven).; Dental implant osseointegration (E/I/unproven).; Depression (E/I/unproven).; Diabetic foot ulcers that are not infected (E/I/unproven).; Diabetic superficial wounds (E/I/unproven).; Enterocutaneous fistula (E/I/unproven).; Epithelial-to-mesenchymal transition (EMT) phenomenon in keloid tissue (E/I/unproven).; Erectile dysfunction (E/I/unproven).; Facial neuritis (E/I/unproven).; Fat necrosis (E/I/unproven).; Fibromyalgia (E/I/unproven).; Frostbite (E/I/unproven).; Glioblastoma (E/I/unproven).; Heart disease (E/I/unproven).; HIV infection (E/I/unproven).; Hypospadias (E/I/unproven).; Infective polyneuritis (E/I/unproven).; Inflammatory bowel disease (Crohn's disease and ulcerative colitis) (E/I/unproven).; Intestinal anastomosis (E/I/unproven).; Interstitial cystitis (E/I/unproven).; Intra-abdominal abscess, pseudomembranous colitis (antibiotic-induced colitis) (E/I/unproven).; Intra-cerebral hemorrhage (including aneurismal subarachnoid hemorrhage) (E/I/unproven).; Intra-cranial abscesses (E/I/unproven).; Ischemia due to lupus vasculitis (E/I/unproven).; Legg-Calve Perthes disease (E/I/unproven).; Lepromatous leprosy (E/I/unproven).; Livedo reticularis (E/I/unproven).; Liver diseases (e.g., hepatic artery thrombosis, hepatic fibrosis, hepatic necrosis, hepatitis, hepatocellular carcinoma, non-alcoholic steatohepatitis, and sepsis-induced liver injury) (E/I/unproven).; Local late radiation toxicity in individuals treated for breast cancer (E/I/unproven).; Lupus vasculitis (E/I/unproven).; Lyme disease (E/I/unproven).; Lymphedema (E/I/unproven).; Male infertility (E/I/unproven).; Malignant bowel obstruction (including small bowel obstruction secondary to pelvic irradiation) (E/I/unproven).; Melasma (E/I/unproven).; Meningitis (E/I/unproven).; Methicillin-resistant Staphylococcus aureus (MRSA) infections (E/I/unproven).; Multiple sclerosis (E/I/unproven).; Myocardial infarction (E/I/unproven).; Necrotizing arachnidism (E/I/unproven).; Noise-induced sensorineural hearing loss (E/I/unproven).; Non-compromised skin grafts and flaps (E/I/unproven).; Non-diabetic cutaneous, decubitus, pressure and venous stasis ulcers (E/I/unproven).; Non-vascular causes of chronic brain syndrome (e.g., Alzheimer's disease, Korsakoff's disease, Pick's disease) (E/I/unproven).; Ophthalmologic diseases (including central retinal vein occlusion, diabetic retinopathy, glaucoma, keratoendotheliosis, radiation injury to the optic nerve, retinal detachment) (E/I/unproven).; Optic neuritis (E/I/unproven).; Optic neuropathy (E/I/unproven).; Organ transplantation and storage (E/I/unproven).; Osteonecrosis of the jaw (except where cause is radiation necrosis, i.e., osteoradionecrosis) (E/I/unproven).; Osteoporosis (E/I/unproven).; Otitis externa (E/I/unproven).; Parkinson's disease (E/I/unproven).; Pathological scars (E/I/unproven).; Peri-anal fistula (E/I/unproven).; Post-concussive syndrome (E/I/unproven).; Post-operative nipple ischemia following mastectomy (E/I/unproven).; Post-organ transplantation re-vascularization (E/I/unproven).; Post-radiation therapy breast pain (E/I/unproven).; Post-traumatic stress disorder (E/I/unproven).; Pouchitis (E/I/unproven).; Pre-operative HBOT for jaw osteomyelitis (E/I/unproven).; Prevention of avascular necrosis (E/I/unproven).; Prevention of radiation-induced complications of the head and neck cancers (E/I/unproven).; Pulmonary emphysema (E/I/unproven).; Pyoderma gangrenosum (E/I/unproven).; Radiation-induced cholangitis, myelitis, enteritis, sarcoma (E/I/unproven).; Radiation-induced gastro-intestinal complications (e.g., diarrhea, pain and rectal bleeding) (E/I/unproven).; Radiation-induced pulmonary fibrosis/injury (E/I/unproven).; Radiation-induced skin necrosis (E/I/unproven).; Radiation injury to the brachial plexus (E/I/unproven).; Raynaud's syndrome (E/I/unproven).; Recto-vaginal fistula (E/I/unproven).; Scleroderma (systemic sclerosis) (E/I/unproven).; Seizure disorders (E/I/unproven).; Sickle cell anemia (E/I/unproven).; Sickle cell crisis or hematuria (E/I/unproven).; Spinal cord ischemia after complex aortic repair (E/I/unproven).; Spinal dural arterio-venous fistula (E/I/unproven).; Spondylodiscitis (E/I/unproven).; Superficial and/or non-infected diabetic ulcers (E/I/unproven).; Surgical wound dehiscence (E/I/unproven).; Systemic inflammatory response syndrome (E/I/unproven).; Tetanus (E/I/unproven).; Tinnitus (E/I/unproven).; Traumatic brain injury (E/I/unproven).; Tumor sensitization to radiotherapy (E/I/unproven).; Vesicocutaneous fistula (E/I/unproven).; Xerostomia/salivary gland dysfunction (E/I/unproven).; CONTRAINDICATION (E/I/unproven and not medically necessary; safety not established): Concurrent administration of doxorubicin, cisplatin, or disulfiram.; CONTRAINDICATION (E/I/unproven and not medically necessary; safety not established): Premature infants (birth prior to 37 weeks gestation).; CONTRAINDICATION (E/I/unproven and not medically necessary; safety not established): Untreated pneumothorax.; Topical HBOT directly administered to the open wound, and limb-specific hyperbaric oxygen pressurization in small limb-encasing devices (E/I/unproven; efficacy not established through well-controlled clinical trials).; Prophylactic HBOT prior to mastectomy (E/I/unproven; effectiveness not established).; Preventive HBOT for improvement of surgical outcome, other than indications listed as medically necessary above (E/I/unproven; effectiveness not established).; Vaporous hyperoxia therapy (VHT) for non-healing diabetic foot wounds (E/I/unproven; effectiveness not established).; Maintenance of split-thickness skin grafts or artificial skin substitutes (not a covered use under compromised skin grafts/flaps indication). Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Does Aetna require prior authorization for Hyperbaric Oxygen Therapy (HBOT)?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: For wounds generally: evaluation with photographic documentation INCLUDING A RULER after every 15 treatments and/or at least every 30 days during administration of HBOT, showing measurable signs of healing (granulation, epithelialization, or progress toward closing).; Compromised skin grafts and flaps: photograph (with ruler) of graft or flap, type of flap, name of surgeon performing the graft or flap, and whether there was surgical exploration; for lower extremity wounds, graft/flap evaluated with photographic documentation (with ruler) after every 20 treatments or 30 days.; Chronic refractory osteomyelitis: radiological diagnosis (X-ray or MRI) OR bone culture confirmation; if wounds present, photographic documentation (with ruler) after every 15 treatments and/or at least every 30 days.; Diabetic lower extremity wounds: photographic (with ruler) documentation; wounds evaluated at least every 30 days during HBOT.; Progressive necrotizing soft tissue infections: photographic documentation (with ruler) of the wound if present; wounds evaluated with photographic documentation (with ruler) after every 15 treatments and/or at least every 30 days.; Acute peripheral arterial insufficiency: imaging documentation of embolus/thrombus (e.g., MR, angiogram).; Idiopathic sudden sensorineural hearing loss: documentation of pure-tone thresholds (>30 dB affecting >3 consecutive frequencies).

What does Aetna exclude for Hyperbaric Oxygen Therapy (HBOT)?

Policy exclusions and limitations: Experimental, investigational, or unproven (not an all-inclusive list) due to insufficient evidence that systemic HBOT is more effective than conventional therapies - the following conditions:; Actinic skin damage (E/I/unproven).; Actinomycosis and other mycoses (E/I/unproven).; Acute cerebral edema (E/I/unproven).; Acute coronary syndrome (E/I/unproven).; Acute kidney injury (E/I/unproven).; Acute or chronic cerebrovascular insufficiency/accident (including thrombotic or embolic stroke) (E/I/unproven).; Acute renal arterial insufficiency (E/I/unproven).; Acute thermal and chemical pulmonary damage, i.e., smoke inhalation (e.g., carbon tetrachloride, hydrogen sulfide) with pulmonary insufficiency (E/I/unproven).; Adhesions prevention after laparotomy (E/I/unproven).; Aerobic septicemia and systemic aerobic infection (E/I/unproven).; Alzheimer's disease (E/I/unproven).; Anaerobic septicemia and infection other than clostridial (E/I/unproven).; Anoxic brain injury (E/I/unproven).; Anti-phospholipid antibody syndrome (E/I/unproven).; Arthritic diseases (E/I/unproven).; Arthritis (E/I/unproven).; Asthma (E/I/unproven).; Autism spectrum disorders (E/I/unproven).; Bacterial keratitis (E/I/unproven).; Bell's palsy (E/I/unproven).; Bone grafts or fracture healing (e.g., nonunion fractures) / bone reconstruction (E/I/unproven).; Brain tumors (E/I/unproven).; Calciphylaxis (calcific uremic arteriolopathy) (E/I/unproven).; Cancer (E/I/unproven).; Cardiogenic shock (E/I/unproven).; Central airway stenosis following lung transplantation (E/I/unproven).; Cerebral palsy (E/I/unproven).; Chemotherapy induced hemorrhagic cystitis (E/I/unproven).; Chronic bowel dysfunction after pelvic radiotherapy (E/I/unproven).; Chronic pain (e.g., cluster headaches, complex regional pain syndrome/reflex sympathetic dystrophy, fibromyalgia, migraines, myofascial pain syndrome, and trigeminal neuralgia) (E/I/unproven).; Chronic peripheral vascular insufficiency (E/I/unproven).; Closed head and/or spinal cord injury (E/I/unproven).; Cognitive impairment (e.g., senility, senile dementia) (E/I/unproven).; Coronary artery disease (E/I/unproven).; COVID-19 (E/I/unproven).; Critical limb ischemia (E/I/unproven).; Cystic acne (E/I/unproven).; Dental implant osseointegration (E/I/unproven).; Depression (E/I/unproven).; Diabetic foot ulcers that are not infected (E/I/unproven).; Diabetic superficial wounds (E/I/unproven).; Enterocutaneous fistula (E/I/unproven).; Epithelial-to-mesenchymal transition (EMT) phenomenon in keloid tissue (E/I/unproven).; Erectile dysfunction (E/I/unproven).; Facial neuritis (E/I/unproven).; Fat necrosis (E/I/unproven).; Fibromyalgia (E/I/unproven).; Frostbite (E/I/unproven).; Glioblastoma (E/I/unproven).; Heart disease (E/I/unproven).; HIV infection (E/I/unproven).; Hypospadias (E/I/unproven).; Infective polyneuritis (E/I/unproven).; Inflammatory bowel disease (Crohn's disease and ulcerative colitis) (E/I/unproven).; Intestinal anastomosis (E/I/unproven).; Interstitial cystitis (E/I/unproven).; Intra-abdominal abscess, pseudomembranous colitis (antibiotic-induced colitis) (E/I/unproven).; Intra-cerebral hemorrhage (including aneurismal subarachnoid hemorrhage) (E/I/unproven).; Intra-cranial abscesses (E/I/unproven).; Ischemia due to lupus vasculitis (E/I/unproven).; Legg-Calve Perthes disease (E/I/unproven).; Lepromatous leprosy (E/I/unproven).; Livedo reticularis (E/I/unproven).; Liver diseases (e.g., hepatic artery thrombosis, hepatic fibrosis, hepatic necrosis, hepatitis, hepatocellular carcinoma, non-alcoholic steatohepatitis, and sepsis-induced liver injury) (E/I/unproven).; Local late radiation toxicity in individuals treated for breast cancer (E/I/unproven).; Lupus vasculitis (E/I/unproven).; Lyme disease (E/I/unproven).; Lymphedema (E/I/unproven).; Male infertility (E/I/unproven).; Malignant bowel obstruction (including small bowel obstruction secondary to pelvic irradiation) (E/I/unproven).; Melasma (E/I/unproven).; Meningitis (E/I/unproven).; Methicillin-resistant Staphylococcus aureus (MRSA) infections (E/I/unproven).; Multiple sclerosis (E/I/unproven).; Myocardial infarction (E/I/unproven).; Necrotizing arachnidism (E/I/unproven).; Noise-induced sensorineural hearing loss (E/I/unproven).; Non-compromised skin grafts and flaps (E/I/unproven).; Non-diabetic cutaneous, decubitus, pressure and venous stasis ulcers (E/I/unproven).; Non-vascular causes of chronic brain syndrome (e.g., Alzheimer's disease, Korsakoff's disease, Pick's disease) (E/I/unproven).; Ophthalmologic diseases (including central retinal vein occlusion, diabetic retinopathy, glaucoma, keratoendotheliosis, radiation injury to the optic nerve, retinal detachment) (E/I/unproven).; Optic neuritis (E/I/unproven).; Optic neuropathy (E/I/unproven).; Organ transplantation and storage (E/I/unproven).; Osteonecrosis of the jaw (except where cause is radiation necrosis, i.e., osteoradionecrosis) (E/I/unproven).; Osteoporosis (E/I/unproven).; Otitis externa (E/I/unproven).; Parkinson's disease (E/I/unproven).; Pathological scars (E/I/unproven).; Peri-anal fistula (E/I/unproven).; Post-concussive syndrome (E/I/unproven).; Post-operative nipple ischemia following mastectomy (E/I/unproven).; Post-organ transplantation re-vascularization (E/I/unproven).; Post-radiation therapy breast pain (E/I/unproven).; Post-traumatic stress disorder (E/I/unproven).; Pouchitis (E/I/unproven).; Pre-operative HBOT for jaw osteomyelitis (E/I/unproven).; Prevention of avascular necrosis (E/I/unproven).; Prevention of radiation-induced complications of the head and neck cancers (E/I/unproven).; Pulmonary emphysema (E/I/unproven).; Pyoderma gangrenosum (E/I/unproven).; Radiation-induced cholangitis, myelitis, enteritis, sarcoma (E/I/unproven).; Radiation-induced gastro-intestinal complications (e.g., diarrhea, pain and rectal bleeding) (E/I/unproven).; Radiation-induced pulmonary fibrosis/injury (E/I/unproven).; Radiation-induced skin necrosis (E/I/unproven).; Radiation injury to the brachial plexus (E/I/unproven).; Raynaud's syndrome (E/I/unproven).; Recto-vaginal fistula (E/I/unproven).; Scleroderma (systemic sclerosis) (E/I/unproven).; Seizure disorders (E/I/unproven).; Sickle cell anemia (E/I/unproven).; Sickle cell crisis or hematuria (E/I/unproven).; Spinal cord ischemia after complex aortic repair (E/I/unproven).; Spinal dural arterio-venous fistula (E/I/unproven).; Spondylodiscitis (E/I/unproven).; Superficial and/or non-infected diabetic ulcers (E/I/unproven).; Surgical wound dehiscence (E/I/unproven).; Systemic inflammatory response syndrome (E/I/unproven).; Tetanus (E/I/unproven).; Tinnitus (E/I/unproven).; Traumatic brain injury (E/I/unproven).; Tumor sensitization to radiotherapy (E/I/unproven).; Vesicocutaneous fistula (E/I/unproven).; Xerostomia/salivary gland dysfunction (E/I/unproven).; CONTRAINDICATION (E/I/unproven and not medically necessary; safety not established): Concurrent administration of doxorubicin, cisplatin, or disulfiram.; CONTRAINDICATION (E/I/unproven and not medically necessary; safety not established): Premature infants (birth prior to 37 weeks gestation).; CONTRAINDICATION (E/I/unproven and not medically necessary; safety not established): Untreated pneumothorax.; Topical HBOT directly administered to the open wound, and limb-specific hyperbaric oxygen pressurization in small limb-encasing devices (E/I/unproven; efficacy not established through well-controlled clinical trials).; Prophylactic HBOT prior to mastectomy (E/I/unproven; effectiveness not established).; Preventive HBOT for improvement of surgical outcome, other than indications listed as medically necessary above (E/I/unproven; effectiveness not established).; Vaporous hyperoxia therapy (VHT) for non-healing diabetic foot wounds (E/I/unproven; effectiveness not established).; Maintenance of split-thickness skin grafts or artificial skin substitutes (not a covered use under compromised skin grafts/flaps indication). Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

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Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT