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AetnaAll Plans · Coverage · Medical Policy · Wound Care, Emergency Medicine, ENT (Ear, Nose & Throat) +9 moreMedium impact

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

Effective date
Not stated in the notice
Identified
Aug 18, 2026

Summary

Aetna considers systemic hyperbaric oxygen therapy (HBOT) medically necessary for conditions including acute air or gas embolism, acute carbon monoxide poisoning, acute thermal burns, decompression sickness, gas gangrene, and chronic refractory stage 3 or 4 osteomyelitis, with usual numbers of sessions listed for each. Continued HBOT for wounds is not considered medically necessary if measurable signs of healing have not been demonstrated within any 30-day period of treatment. Aetna considers systemic HBOT experimental, investigational, or unproven for conditions including Alzheimer's disease, autism spectrum disorders, traumatic brain injury, and COVID-19, and considers topical HBOT and vaporous hyperoxia therapy for non-healing diabetic foot wounds experimental, investigational, or unproven.

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What to do

Action · 5 steps
01Claims for systemic HBOT under HCPCS G0277 (per 30 minute interval) and physician attendance and supervision under CPT 99183 (per session) need the selection criteria in the policy met.
02Wounds need photographic documentation with a ruler after every 15 treatments and/or at least every 30 days during HBOT, and continued treatment is not considered medically necessary if measurable signs of healing have not been demonstrated within any 30 day period.
03For compromised skin grafts and flaps, the required documentation includes a photograph with a ruler of the graft or flap, the type of flap, the name of the surgeon performing the graft or flap, and whether there was surgical exploration.
04HCPCS A4575 (topical hyperbaric oxygen chamber, disposable) and E0446 (topical oxygen delivery system) are listed as not covered.
05Systemic HBOT is considered experimental, investigational, or unproven and not medically necessary for members with concurrent administration of doxorubicin, cisplatin, or disulfiram, for premature infants (birth prior to 37 weeks gestation), and for untreated pneumothorax.

Codes mentioned

99183G0277A4575E0446A41.4A48.0M72.6N30.41K62.7T70.3XXA

Original notice

Hyperbaric Oxygen Therapy (HBOT) (CPB 0172, reviewed 2026-04-21)
aetna.com · Always check the source before changing claims.
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Related changes

See all Aetna changes →
Dysphagia Therapy (CPB 0625, reviewed 2026-10-21)MediumNo effective date · Medical PolicyDysphagia Therapy (CPB 0625, reviewed 2025-09-25)MediumNo effective date · Medical PolicyAlzheimer's Disease: Experimental, Investigational, or Unproven Treatments (CPB 0788, reviewed 2025-11-19)MediumNo effective date · Medical PolicyXerostomia: Selected Treatments (CPB 0302, reviewed 2026-04-14)MediumNo effective date · Medical PolicyBrowse every Aetna change in the policy list

Related policy hubs

Aetna policiesWound CareEmergency MedicineENT (Ear, Nose & Throat)OphthalmologyNeurologyOral & Maxillofacial SurgeryRadiation OncologyGastroenterologyPlastic SurgeryPodiatryVascular SurgeryOrthopedicsCode 99183Code G0277Code A4575Code E0446Code A41.4Code A48.0Code M72.6Code N30.41Code K62.7Code T70.3XXA

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