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Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state: 
A. Covered Conditions 
Program reimbursement for HBO therapy will be limited to that which is administered in a chamber (including 
the one-man unit) and is limited to the following conditions: 
1. Acute carbon monoxide intoxication, 
2. Decompression illness, 
3. Gas embolism, 
4. Gas gangrene, 
5. Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in 
combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened. 
6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an 
adjunctive treatment when loss of function, limb, or life is threatened. 
7. Progressive necrotizing infections (necrotizing fasciitis), 
8. Acute peripheral arterial insufficiency, 
9. Preparation and preservation of compromised skin grafts (not for primary management of wounds), 
10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management, 
11. Osteoradionecrosis as an adjunct to conventional treatment, 
12. Soft tissue radionecrosis as an adjunct to conventional treatment, 
13. Cyanide poisoning, 
14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to 
antibiotics and surgical treatment, 
15. Diabetic wounds of the lower extremities in patients who meet the following three criteria: 
a. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; 
b. Patient has a wound classified as Wagner grade III or higher; and 
c. Patient has failed an adequate course of standard wound therapy. 
  
The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing 
for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound 
care. Standard wound care in patients with diabetic wounds includes assessment of a patients vascular status and correction of any 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 a 
clean, moist bed of granulation tissue with appropriate moist dressings, appropriate off-loading, and necessary 
treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when 
there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least 
every 30 days during administration of HBO therapy. Continued treatment with HBO therapy is not covered if 
measurable signs of healing have not been demonstrated within any 30-day period of treatment. 
 
B. Noncovered Conditions 
All other indications not specified under 270.4(A) are not covered under the Medicare program. No program 
payment may be made for any conditions other than those listed in 270.4(A). 
No program payment may be made for HBO in the treatment of the following conditions: 
1. Cutaneous, decubitus, and stasis ulcers. 
2. Chronic peripheral vascular insufficiency. 
3. Anaerobic septicemia and infection other than clostridial. 
4. Skin burns (thermal). 
5. Senility. 
6. Myocardial infarction. 
7. Cardiogenic shock. 
8. Sickle cell anemia. 
9. Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency. 
10. Acute or chronic cerebral vascular insufficiency. 
11. Hepatic necrosis. 
12. Aerobic septicemia. 
13. Nonvascular causes of chronic brain syndrome (Picks disease, Alzheimers disease, Korsakoffs 
disease). 
14. Tetanus. 
15. Systemic aerobic infection. 
16. Organ transplantation. 
17. Organ storage. 
18. Pulmonary emphysema. 
19. Exceptional blood loss anemia. 
20. Multiple Sclerosis. 
21. Arthritic Diseases. 
22. Acute cerebral edema. 
C. Topical Application of Oxygen 
Section C-Topical Application of Oxygen has been removed from NCD 20.29. Effective for dates of service on 
and after (04/03/17), Medicare Administrative Contractors (MACs) acting within their respective jurisdictions 
may determine coverage of topical application of oxygen for chronic non-healing wounds.  
 
You can find this rule in the Medicare National Coverage Determination (NCD)- 20.29, Hyperbaric Oxygen 
Therapy. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.