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TRICARE Policy Manual 6010.60-M, April 1, 2015
Medicine
Chapter 7
Section 20.1
Hyperbaric Oxygen (HBO) Therapy
Issue Date:  October 7, 1982
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-30, August 15, 2018
1.0  CPT PROCEDURE CODE
99183
2.0  DESCRIPTION
HBO therapy is a mode of medical treatment in which the patient is entirely enclosed in a pressure chamber breathing oxygen at a pressure greater than one atmosphere.
3.0  POLICY
3.1  Benefits are allowed for HBO therapy only when provided by an approved institutional provider, such as a hospital.
3.2  HBO therapy (CPT procedure code 99183) may be covered for the following indications:
•  Decompression sickness
•  Carbon monoxide poisoning
•  Air or gas embolism
•  Profound blood loss, when blood transfusion cannot be accomplished.
3.3  HBO therapy (CPT procedure code 99183) may be covered as an adjunct to standard therapy for the following indications:
•  Acute soft tissue injury (i.e., crush injury, compartment syndrome, acute traumatic peripheral ischemia, blast injury)
•  Clostridial myositis and myonecrosis
•  Compromised skin grafts and/or flaps
•  Chronic, severe, and/or gangrenous diabetic foot wounds
•  Ostoradionecrosis
•  Osteomyelitis refractory to standard medical management.
3.4  HBO may be covered for other indications when documented by reliable evidence as safe, effective, and comparable or superior to standard care (proven).
4.0  EXCLUSIONS
4.1  HBO therapy for Traumatic Brain Injury (TBI) is unproven.
4.2  HBO therapy for stroke is unproven.
4.3  HBO therapy for cerebral palsy is unproven.
4.4  HBO therapy for autism is unproven.
4.5  HBO therapy as an adjunct therapy for the treatment of thermal burns is unproven.
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