Physician attendance and supervision of hyperbaric oxygen therapy, per session

CPT codes not covered for indications listed in the CPB:

• Vaporous hyperoxia therapy (VHT) -hyphenno specific code

Other CPT codes related to the CPB:

• Mastectomy

HCPCS codes covered if selection criteria are met:

• Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

HCPCS codes not covered for indications listed in the CPB:

• Topical hyperbaric oxygen chamber, disposable
• Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories

Other HCPCS codes related to the CPB:

• Injection, doxorubicin HCl, 10 mg
• Injection, cisplatin, powder or solution, 10 mg
• Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg

ICD-hyphen10 codes covered if selection criteria are met:

• Septicemia due to anaerobes [progressive necrotizing soft tissue anaerobic infections]
• Gas gangrene [Clostridial myositis and myonecrosis]
• Iron deficiency anemia secondary to blood loss (chronic) [overwhelming and transfusion is impossible because there is no suitable blood available or religion does not permit]
• Acute posthemorrhagic anemia [overwhelming and transfusion is impossible because there is no suitable blood available or religion does not permit]
• Diabetes mellitus with circulatory complications [non-healing infected deep ulcerations (reaching tendons or bone) of the lower extremity unresponsive to at least 1 month of meticulous wound care, including aggressive debridement, maximal antibiotic therapy, tight glycemic control, and appropriate treatment of arterial insufficiency, including revascularization if necessary]
• Diabetes mellitus with other specified complications [non-healing infected deep ulcerations (reaching tendons or bone) Wagner grade 3 of the lower extremity]
• Central retinal artery occlusion
• Sensorineural hearing loss, bilateral [not covered for noise-induced sensorineural hearing loss]
• Sudden idiopathic hearing loss [idiopathic when HBOT is initiated within 3 months after onset]
• Atherosclerosis of native arteries and bypass graft(s) of the extremities [non-healing infected deep ulcerations (reaching tendons or bone) of the lower extremity unresponsive to at least 1 month of meticulous wound care, including aggressive debridement, maximal antibiotic therapy, tight glycemic control, and appropriate treatment of arterial insufficiency, including revascularization if necessary]
• Other aneurysm of extremities
• Other peripheral vascular disease [acute peripheral arterial insufficiency]
• Arterial embolism of the extremities [acute peripheral arterial insufficiency]
• Arterial embolism and thrombosis of the iliac artery [acute peripheral arterial insufficiency]
• Other disorders of arteries, arterioles and capillaries in diseases classified elsewhere [acute peripheral arterial insufficiency]
• Varicose veins of lower extremities with ulcer [non-healing infected deep ulcerations (reaching tendons or bone) of the lower extremity unresponsive to at least 1 month of meticulous wound care, including aggressive debridement, maximal antibiotic therapy, tight glycemic control, and appropriate treatment of arterial insufficiency, including revascularization if necessary]
• Varicose veins of lower extremities with both ulcer and inflammation [non-healing infected deep ulcerations (reaching tendons or bone) of the lower extremity unresponsive to at least 1 month of meticulous wound care, including aggressive debridement, maximal antibiotic therapy, tight glycemic control, and appropriate treatment of arterial insufficiency, including revascularization if necessary]
• Gangrene not elsewhere classified [Meleney’s ulcer]
• Radiation proctitis
• Non-pressure chronic ulcer of lower limb [diabetic ulcers] [non-healing infected deep ulcerations (reaching tendons or bone) Wagner grade 3 of the lower extremity]
• Other specified diseases of jaw [prophylactic pre- and post-treatment for members undergoing dental surgery of a radiated jaw]
• Necrotizing fasciitis
• Chronic osteomyelitis [not covered pre-operative for jaw]
• Irradiation cystitis with hematuria
• Obstetric air embolism in pregnancy
• Crushing injuries [when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy]
• Injury to the iliac artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy]
• Injury to axillary artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy]
• Injury of brachial artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy]
• Traumatic amputation thumb, finger(s), arm and hand [when loss of function or life is threatened and HBOT is used in combination with standard therapy]
• Injury to other specified blood vessels of the upper extremity [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy]
• Injury of ulnar artery at wrist and hand level [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy]
• Injury of radial artery at wrist and hand level [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy]
• Injury to palmar artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy]
• Injury of femoral artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy]
• Injury to other specified blood vessels of the lower extremity [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy]
• Traumatic amputation toe(s), foot, leg(s) [when loss of function or life is threatened and HBOT is used in combination with standard therapy]
• Injury to popliteal artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy]
• Injury to anterior tibial artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy]
• Injury to posterior tibial artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy]
• Injury of peroneal artery [acute peripheral ischemia when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy]
• Toxic effect of hydrogen cyanide [with co-existing carbon monoxide poisoning]
• Toxic effect of carbon monoxide [acute]
• Toxic effect of cyanides [with co-existing carbon monoxide poisoning]
• Radiation sickness, unspecified [radiation necrosis]
• Caisson disease [decompression illness]
• Air embolism (traumatic) [acute]
• Traumatic compartment syndrome
• Infection following a procedure [reaching tendons or bone of the lower extremity unresponsive to at least 1 month of meticulous wound care, including aggressive debridement, maximal antibiotic therapy, tight glycemic control, and appropriate treatment of arterial insufficiency, including revascularization if necessary]
• Other complications of procedures, not elsewhere classified (reaching tendons or bone) of the lower extremity unresponsive to at least 1 month of meticulous wound care, including aggressive debridement, maximal antibiotic therapy, tight glycemic control, and appropriate treatment of arterial insufficiency, including revascularization if necessary]
• Other mechanical complication of artificial skin graft and decellularized allodermis [compromised skin grafts and flaps]
• Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts [compromised skin grafts and flaps]
• Other specified complications of internal prosthetic devices, implants and grafts, not elsewhere classified [compromised skin grafts and flaps]
• Complications of skin graft (allograft) (autograft) [compromised skin grafts and flaps]

ICD-hyphen10 codes not covered for indications listed in the CPB (not all-hypheninclusive):

• Salmonella meningitis
• Enterocolitis due to Clostridium difficile [intra-abdominal abscess, pseudomembranous colitis (antibiotic-induced colitis)]
• Tuberculous meningitis
• Aseptic meningitis in leptospirosis
• Lepromatous leprosy
• Other tetanus
• Meningococcal meningitis
• Sepsis [except sepsis due to anaerobes]
• Actinomycotic infections
• Methicillin-resistant Staphylococcus aureus infection, unspecified site
• Late congenital syphilitic meningitis
• Secondary syphilitic meningitis
• Late syphilitic meningitis
• Gonococcal meningitis
• Lyme disease
• Viral hepatitis
• Human immunodeficiency virus [HIV] disease
• Mycoses
• Malignant neoplasm [cancer]
• Malignant neoplasm of the brain [glioblastoma]
• In situ neoplasms [cancer]
• Hb-SS disease with crisis [sickle cell crisis]
• Antiphospholipid syndrome
• Lupus anticoagulant syndrome
• Type 2 diabetes mellitus with ophthalmic complications
• Disorders of zinc metabolism
• Other disorders of calcium metabolism [calciphylaxis (calcific uremic arteriolopathy)]
• Dementias [cognitive impairment]
• Other persistent mental disorders due to conditions classified elsewhere [dementia NOS] [cognitive impairment]
• Personality change due to a known physiological condition [cognitive impairment]
• Postconcussional syndrome
• Other personality and behavioral disorders due to a known physiological condition [cognitive impairment]
• Depression
• Post-traumatic stress disorder
• Pervasive and specific developmental disorders
• Autistic disorder
• Bacterial meningitis due to other organisms and of unspecified cause
• Intracranial abscess and granuloma
• Parkinson’s disease
• Other drug-induced secondary parkinsonism
• Alzheimer’s disease and other degenerative diseases of the nervous system [cognitive impairment]
• Multiple sclerosis
• Acute transverse myelitis in demyelinating diseases of the central nervous system [radiation-induced]
• Epilepsy and recurrent seizures
• Migraine
• Cluster headaches
• Transient cerebral ischemic attacks and related syndromes [acute or chronic cerebrovascular insufficiency]
• Other specified cerebrovascular diseases [acute or chronic cerebrovascular insufficiency/accident including thrombotic or embolic stroke]
• Bell’s palsy
• Other disorders of the facial nerve [facial neuritis]
• Guillain-Barre syndrome
• Cerebral palsy
• Chronic pain, not elsewhere classified
• Chronic pain syndrome
• Complex regional pain syndrome I (CRPSI)
• Anoxic brain damage, not elsewhere classified
• Cerebral edema [acute]
• Diseases of the eye and adnexa [except central retinal artery occlusion]
• Otitis externa
• Noise effects on the inner ear [noise-induced sensorineural hearing loss]
• Sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side [noise-induced sensorineural hearing loss]
• Unspecified sensorineural hearing loss [noise-induced sensorineural hearing loss]
• Tinnitus
• Ischemic heart diseases
• Heart disease
• Nontraumatic intracerebral hemorrhage
• Cerebral infarction and occlusion and thrombosis of precerebral and cerebral arteries, not resulting in cerebral infarction [acute or chronic cerebrovascular insufficiency/accident including thrombotic or embolic stroke]
• Other cerebrovascular diseases [acute or chronic cerebrovascular insufficiency/accident including thrombotic or embolic stroke]
• Cognitive deficits following unspecified cerebrovascular disease
• Raynaud’s syndrome
• Arterial embolism and thrombosis of other arteries [hepatic]
• Arteriovenous fistula, acquired [spinal dural]
• Arteritis, unspecified [Lupus vasculitis]
• Lymphedema
• Emphysema
• Other chronic obstructive pulmonary disease [bronchitis with emphysema]
• Asthma
• Respiratory conditions due to inhalation of chemicals, gases, fumes, and vapors [Acute thermal and chemical pulmonary damage, i.e., smoke inhalation (e.g., carbon tetrachloride, hydrogen sulfide) with pulmonary insufficiency]
• Respiratory conditions due to other external agents [Acute thermal and chemical pulmonary damage, i.e., smoke inhalation (e.g., carbon tetrachloride, hydrogen sulfide) with pulmonary insufficiency]
• Pulmonary fibrosis, unspecified [radiation induced]
• Other diseases of the bronchus, not elsewhere classified [central airway stenosis following lung transplantation]
• Disturbances and diseases of salivary glands
• Crohn’s disease [regional enteritis]
• Ulcerative colitis
• Gastroenteritis and colitis due to radiation [Radiation-induced gastrointestinal complications]
• Other intestinal obstruction [small bowel obstruction]
• Anal fistula
• Fistula of the intestine [enterocutaneous fistulae]
• Other specified diseases of the intestine [intestinal anastomosis]
• Peritoneal abscess [intra-abdominal]
• Diseases of the liver
• Acute and subacute hepatic failure
• Chronic hepatitis, NEC
• Cholangitis [radiation-induced hemorrhagic]
• Other local infections and disorders of the skin and subcutaneous tissue [except Meleney’s ulcer] [infection other than clostridial]
• Contact dermatitis and other eczema due to solar radiation [actinic skin damage]
• Other disorders of the skin and subcutaneous tissue related to radiation [radiation-induced skin necrosis]
• Acne vulgaris [cystic]
• Chloasma [melasma]
• Hypertrophic scar [epithelial-to-mesenchymal transition (EMT) phenomenon in keloid tissue]
• Arthropathies
• Endosseous dental implant failure
• Systemic lupus erythematosus (SLE) [ischemia due to lupus vasculitis]
• Systemic sclerosis [scleroderma]
• Pathologic fracture [fracture healing]
• Nontraumatic ischemic infarction of muscle [critical limb ischemia]
• Myalgia [myofascial pain syndrome]
• Fibromyalgia
• Osteoporosis without current pathological fracture
• Idiopathic aseptic necrosis of bone
• Juvenile osteochondrosis of the head of the femur [Legg-Calve-Perthes]
• Interstitial cystitis (chronic)
• Other cystitis with hematuria [Chemotherapy-induced hemorrhagic cystitis]
• Vesical fistula, not elsewhere classified
• Male infertility
• Male erectile dysfunction
• Mastodynia [post-radiation therapy]
• Other female intestinal-genital tract fistulae [rectovaginal fistula]
• Disruption of cesarean delivery wound
• Interstitial emphysema and related conditions originating in the perinatal period
• Congenital glaucoma
• Hypospadias
• Hereditary lymphedema [legs]
• Pallor [Livedo reticularis]
• Hematuria
• Neurologic neglect syndrome [cognitive impairment]
• Age-related cognitive decline
• Altered mental status [cognitive impairment]
• Convulsions, not elsewhere classified
• Cardiogenic shock
• Systemic inflammatory response syndrome (SIRS) of non-infectious origin
• Injury of optic nerve and pathways [ophthalmologic diseases (including diabetic retinopathy, retinal detachment, central retinal artery occlusion, radiation injury to the optic nerve, glaucoma, keratoendotheliosis)]
• Intracranial injury [cognitive impairment] [not covered for traumatic brain injury]
• Specified and unspecified head injury [cognitive impairment] [closed head injury]
• Other and unspecified injury of cervical, thoracic, lumbar and sacral spinal cord
• Burns and corrosions of head, face, neck, trunk, upper limb, wrist and hand, lower limb, and multiple and unspecified body regions [skin, thermal]
• Frostbite [face, hand, foot, and other and unspecified sites]
• Toxic effects of other gases, fumes, or vapors [other than carbon monoxide] [Acute thermal and chemical pulmonary damage, i.e., smoke inhalation (e.g., carbon tetrachloride, hydrogen sulfide) with pulmonary insufficiency]
• Toxic effect of contact with venomous animals and plants [necrotizing arachnidism]
• Disruption of wound [dehiscence of operation wound]
• Mechanical complication of internal orthopedic devices, implants and grafts [bone grafts]
• Infection and inflammatory reaction due to internal fixation devices and other internal orthopedic prosthetic devices, implants and grafts [bone grafts]
• COVID-19
• Encounter for prophylactic removal of the breast
• Encounter for aftercare following organ transplant [post organ transplant revascularization]
• Awaiting organ transplant status [organ transplant or storage]
• Transplanted organ and tissue status, and presence of cardiac and vascular implants and grafts and other functional implants and other devices [organ transplant or storage]
• Aftercare for healing fracture [Codes not listed due to expanded specificity]
• Fractures, including malunion and nonunion [Codes not listed due to expanded specificity]
• Intracranial injury, sequela [Codes not listed due to expanded specificity]

ICD-hyphen10 codes contraindicated for this CPB:

• Viral infections and diseases
• Diseases of the respiratory system [lung disease including J93.0 – J93.9 untreated pneumothorax]
• Hereditary spherocytosis [congenital]
• Disorders of newborn related to short gestation and low birth weight, not elsewhere classified [premature infants (birth prior to 37 weeks)]
• Fever [high]