Notification Issue Date:

Policy Attachment

Attachment to Policy # 07.00.03n


Policy #:07.00.03n

Description:Utilization Guidelines

Title:Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy

Utilization Guidelines

Utilization guidelines are presented relative to specific treatment conditions. The diagnosis should be established by the referring or treating professional provider prior to the initiation of HBO therapy.

HBO therapy should not be a replacement for other standard successful therapeutic measures. Depending on the response of the individual and the severity of the original problem, treatment may range from less than 1 week to several months duration, the average being 2 to 4 weeks. The use of HBO therapy for more than 20 treatment sessions, or conditions being treated over the recommended treatment sessions, regardless of the condition of the individual, may be subject to review for medical necessity before further reimbursement is made.

Typical Dose
Utilization Review
Actinomycosis2-3 ATA
20-40 sessions
40 treatments
Carbon monoxide poisoning, acuteUp to 3 ATA
1-3 sessions
3 treatments
Crush injury
Compartment syndrome
Acute traumatic ischemia
2-2.4 ATA 2 times/day
2-7 days
15 treatments
Air or gas embolismUS Navy Treatment Table 6 or equivalent
1-2 sessions, or to clinical plateau
10 treatments
Refractory osteomyelitis2-3 ATA
20-40 sessions
40 treatments
Decompression sicknessUS Navy Treatment Table 6 or equivalent
1 to clinical plateau
10 treatments
Severe anemia2-3 ATA 3-4 times per day until replacement of red blood cells by regeneration or transfusion
Individualized based on clinical response
Clostridial myositis
Clostridial myonecrosis
2.4-3.0 ATA 3 times in first 24 hours
Twice daily for the next 2-5 days
10 treatments
Intracranial abscess2-2.5 ATA
1-2 times/day
Up to 3 weeks
20 treatments
Necrotizing soft tissue infection2-2.5 ATA
Twice daily until stabilization
30 treatments
Compromised skin grafts and flaps2-2.5 ATA
Twice daily up to 20 sessions
20 treatments
Delayed radiation injury:
Soft tissue radionecrosis
Bony radionecrosis (osteoradionecrosis)
2-2.5 ATA
For radiation injury: 30 - 60 sessions
For prophylaxis: 20 sessions before surgery in radiated field
10 sessions after surgery
30 - 60 treatments
Acute thermal burn injury2-2.4 ATA
Twice daily
Up to 30 sessions
30 treatments
Diabetic Foot Ulcer2-2.5 ATA
Daily for 3-4 weeks, based on healing response
Every 30 days

Version Effective Date: 12/01/2016
Version Issued Date: 12/01/2016
Version Reissued Date: 12/19/2019

2017 AmeriHealth.