Does Medi-Cal, Kaiser, Blue Shield or Anthem Cover Hyperbaric Oxygen Therapy?

According to the Medi-Cal Provider Manual section on hyperbaric oxygen therapy, HBOT is a covered benefit when it is medically necessary. The manual sets out a few firm rules:

• A Treatment Authorization Request is required for all hyperbaric oxygen services.
• The TAR must include the appropriate ICD-10-CM diagnosis code.
• Reimbursement is limited to hospitals, hospital outpatient departments and physicians' offices.
• Topical oxygen therapy is not a covered benefit.

Many Medi-Cal members in Stanislaus County are enrolled in a Medi-Cal managed care plan. Those plans apply the same medical-necessity standard through their own authorization process. Your plan's member services line can tell you which facilities it works with. For the local picture, see our Stanislaus and San Joaquin County service area.

Because the provider must bill Medi-Cal for Medi-Cal to pay, the facility you choose matters. Generations Wellness does not bill Medi-Cal at this time.

Blue Shield of California's medical policy considers systemic HBOT (a full-body chamber) medically necessary for conditions outlined by the UHMS. Examples in the policy include:

• Carbon monoxide and cyanide poisoning
• Gas embolism
• Acute traumatic ischemia
• Central retinal artery occlusion
• Chronic refractory osteomyelitis
• Compromised skin grafts and flaps
• Diabetic wounds that meet the policy's criteria
• Delayed radiation injury

The policy considers topical oxygen therapy investigational. Prior authorization and network rules depend on your specific Blue Shield plan.

UnitedHealthcare

UnitedHealthcare publishes a commercial medical policy titled "Hyperbaric Oxygen Therapy and Topical Oxygen Therapy." It lists the conditions for which systemic HBOT is covered, closely matching the recognized list, and explains when prior authorization applies.

Aetna

Aetna publishes a clinical policy bulletin on hyperbaric oxygen therapy. Its covered conditions follow the same general pattern. Ask Aetna for the current bulletin and its authorization steps.

Health Net

Health Net, which offers commercial and Medi-Cal plans in California, applies its own medical policy for HBOT. Because Health Net has several plan types, ask member services which policy and approval process apply to your plan.

TRICARE

TRICARE's policy manual lists the hyperbaric indications it covers, which follow the recognized medical list. Authorization and referral rules depend on your TRICARE plan, so check with your regional contractor before scheduling.

The VA

Veterans can receive HBOT for covered indications through VA care, or through VA community care when the VA authorizes it in advance. Traumatic brain injury and PTSD are not FDA-cleared indications for HBOT, and the VA's Evidence Synthesis Program has reviewed the research on those uses. HBOT for them is not standard VA care. For a summary of that evidence, see the VA position on TBI and PTSD in our research section.

Workers' compensation

If a work injury led to a covered condition, such as a crush injury or a wound that meets criteria, workers' compensation may be another route. Ask the claims administrator how it handles HBOT requests.

1. Get the reason in writing. The denial letter must explain why and tell you how to appeal and by when.
2. Sort the reason. "Not a covered indication" means the condition is outside the policy, and appeals rarely change that. "Documentation insufficient" is often fixable, for example by adding the wound grade, records of 30 days of standard care, or photos.
3. Ask your physician to help. A peer-to-peer call with the plan's reviewer, or a letter of medical necessity, can address missing details.
4. Use outside review if needed. For plans regulated by California's Department of Managed Health Care, you can request an Independent Medical Review after the plan's internal appeal. Medi-Cal members can appeal with their plan and then ask for a State Hearing.

If HBOT is not covered for your condition, it is self-pay in any setting. Health savings and flexible spending accounts are generally eligible when HBOT is prescribed by a physician for a medical condition; confirm with your plan administrator.