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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 say that program reimbursement for hyperbaric oxygen therapy (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. 
 
You can find this rule in National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29) - 
Effective June 19, 2006. 
 The rules say that no program payment may be made for hyperbaric oxygen therapy (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. 
 
You can find this rule in National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29) - 
Effective June 19, 2006. 
 
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.