Hyperbaric Oxygen Therapy (HBOT) (CPB 0172, reviewed 2026-04-21)

IMMEDIATELY: (1) Billing team must update prior authorization workflows in billing software to reflect the 23+ covered HBOT indications with their specific session limits (e.g., acute CO poisoning: 1-3 sessions; diabetic lower extremity wounds: up to 40-60 sessions; radiation necrosis: up to 40+10 sessions). (2) Coding/documentation staff must establish internal checklists requiring providers to submit with HBOT claims: specific diagnosis/indication, photographic documentation with ruler (for wound cases), evidence of 30+ days standard care failure (for diabetic wounds), imaging documentation (for arterial insufficiency), and proof of prior treatment attempts (e.g., 6 weeks antibiotics for osteomyelitis). (3) Update denial response templates to reference the 30-day healing progress requirement—if no measurable healing demonstrated within 30 days, deny continuation and communicate to providers that further sessions are not medically necessary per policy. (4) Configure system alerts: for wound-related HBOT (diabetic ulcers, osteomyelitis, grafts, necrotizing infections), require photographic evidence submission after every 15 treatments AND at minimum every 30 days; flag claims lacking this documentation for denial. (5) Providers and wound care coordinators must be notified via bulletin that effective 2026-04-21, HBOT claims lacking required documentation (especially photographic evidence for wound cases and proof of standard care failure for diabetic wounds) will be denied. (6) For refractory osteomyelitis cases, ensure documentation confirms Stage 3 or 4 diagnosis via X-ray/MRI/culture AND at least 6 weeks parenteral antibiotics AND at least one surgical debridement attempt before authorizing HBOT. Failure to implement these requirements will result in high claim denial rates and provider disputes.