MP9055 Covered Service: Prior Authorization Required: Additional Information: Yes when meets criteria below Yes-as shown below None Prevea360 Health Plan Medical Policy: 1.0 Hyperbaric Oxygen therapy (HBO) for the treatment of chronic severe diabetic ulcer(s) requires prior authorization through the Quality and Care and may be considered medically necessary when the need for initial treatment is indicated by ALL of the following (1.1-1.4) 1.1 Evaluation and treatment of underlying peripheral vascular or neuropathic disease 1.2 Minimal to no healing present (i.e., less than 50%) despite conventional wound treatment for four (4) weeks, including ALL of the following: 1.2.1 Optimal glycemic control; AND 1.2.2 Pressure reduction or offloading; AND 1.2.3 Topical wound treatment (eg, saline, hydrogels, hydrocolloids, alginates) ; AND 1.2.4 Wound debridement; AND 1.2.5 Wound is not infected, or infected wound has been treated with antibiotics. 1.3 Severe wound documented as indicated by 1 or more of the following: 1.3.1 Deep ulcer to tendon, capsule, or bone; OR 1.3.2 Deep ulcer with abscess, osteomyelitis, or joint sepsis; OR 1.3.3 Localized gangrene of forefoot or heel; OR 1.4 Transcutaneous tissue oxygenation (PtcO2) levels of 1 or more of the following: 1.4.1 PtcO2 of 25 mm Hg (3.3 kpa) or greater on room air; OR 1.4.2 PtcO2 value less than 25 mm Hg (3.3 kpa) on room air that increases by 1 or more of the following: 1.4.2.1 PtcO2 increase of more than 20 mm Hg (2.7 kpa) while breathing 100% oxygen via face mask at normal atmospheric pressure; OR 1.4.2.2 PtcO2 level greater than 200 mm Hg (26.6 kpa) in chamber during hyperbaric oxygen therapy 1 of 5
1.5 Chronic severe diabetic ulcer, and need for continued treatment, as indicated by ALL of the following: 1.5.1 Adherent to hyperbaric oxygen therapy; AND 1.5.2 Evidence of improvement after 24 treatments; AND 1.5.3 Fewer than 40 total treatments 2.0 HBO therapy for the following indications requires prior authorization: 2.1 Chronic refractory osteomyelitis unresponsive to conventional medical and surgical management 2.2 Idiopathic sudden deafness, acoustic trauma or noise-induced hearing loss, when HBO therapy is initiated within 3 months of onset 2.3 Pneumatosis cystoids intestinalis 2.4 Preparation and preservation of compromised skin grafts 2.5 Prophylactic pre- and post-treatment for members undergoing dental surgery of a radiated jaw 2.6 Radiation induced hemorrhagic cystitis 2.7 Radiation necrosis (brain radionecrosis, myoradionecrosis, osteoradionecrosis, and other soft tissue radiation necrosis) as an adjunct to conventional treatment 2.8 Radiation proctitis 3.0 HBO therapy for the following acute conditions does not require prior authorization: 3.1 Acute carbon monoxide poisoning 3.2 Acute peripheral arterial insufficiency (ie. compartment syndrome) 3.3 Acute traumatic peripheral ischemia (including crush injuries and suturing of severed limbs) when loss of function, limb, or life is threatened and HBOT is used in combination with standard therapy 3.4 Clostridial myonecrosis (Gas Gangrene) 3.5 Cyanide poisoning 3.6 Decompression illness 3.7 Progressive necrotizing infections 3.8 Acute Air orgas embolism 3.9 Acute cerebral edema 3.10Emergent anemia, meeting one of the following criteria: 3.10.1 Active hemolysis with rapidly progressive anemia; or 3.10.2 Active massive hemorrhage; or 2 of 5
3.10.3 Severe signs or symptoms unresponsive to volume replacement (e.g. tachycardia, hypotension, chest pain, cognitive impairment); or 3.10.4 Patient unable or unwilling to receive red blood cell transfusions 4.0 HBO therapy is considered experimental and investigational for members with any of the following contraindications to systemic HBO therapy as the safety of systemic HBO therapy for persons with these contraindications to HBO therapy has not been established: 4.1 Concurrent administration of doxorubicin, cisplatin, or disulfiram 4.2 Premature infants (birth prior to 37 weeks gestation) 4.3 Untreated pneumothorax 5.0 Medical evidence does not support the use of HBO therapy for all other indications. It is considered experimental/investigational and therefore it is not a covered service. 3 of 5
Committee/Source Date(s) Originated: QA/UR Committee August 20, 1991 Revised: Reviewed: Utilization Management Committee/Concurrent Review Dept. Utilization Management Committee/ HAYES, Inc. Utilization Management Committee/ Medicare Part B, 7/2000 Utilization Management Committee/ Medical Director/ Medicare Part B 5/2003 Utilization Management Committee/Medical Affairs Utilization Management Committee/Medical Affairs Health Services Managed Care Division/ Medical Affairs Department Managed Care Division / Medical Affairs Department Utilization Management Committee/CMO/Director UM Reformatted September 10, 1997 September 8, 1999 February 14, 2001 September 10, 2003 April 12, 2006 July 9, 2008 June 16, 2010 April 17, 2013 April 20, 2016 April 19, 2017 February 21, 2018 February 23, 1999 March 20, 2000 April 11, 2001 March 13, 2002 March 10, 2004 March 9, 2005 October 2005 March 8, 2006 March 14, 2007 March 12, 2008 April 8, 2009 June 16, 2010 June 23, 2011 June 20, 2012 August 15, 2012 April 17, 2013 April 16, 2014 April 15, 2015 April 20, 2016 4 of 5
Reviewed: Committee/Source Date(s) April 19, 2017 February 21, 2018 Published/Effective: 03/01/2018 5 of 5