Hyperbaric Oxygen Therapy (HBOT) is a medical treatment where a patient breathes 100% oxygen inside a pressurized chamber. This process dramatically increases the amount of oxygen dissolved in the blood plasma, allowing it to reach areas of the body where circulation is poor or blocked. Medicare coverage for this therapy is extremely specific and conditional, determined by the Centers for Medicare & Medicaid Services (CMS).
Specific Medical Conditions Approved for Coverage
Medicare coverage for HBOT is strictly limited to a fixed list of medical conditions defined by the National Coverage Determination (NCD 20.29). Covered indications often involve acute, life- or limb-threatening situations where oxygen acts as an adjunctive treatment to standard medical care. Conditions like decompression illness, carbon monoxide intoxication, and gas embolism are included because HBOT helps rapidly reduce the size of gas bubbles and flush toxins from the bloodstream.
A significant portion of covered HBOT treatments focuses on chronic wounds and tissue damage. Coverage is extended to diabetic wounds of the lower extremities, but only if the patient has a wound classified as Wagner grade III or higher and has failed an adequate course of standard wound therapy for at least 30 consecutive days. Medicare also covers chronic refractory osteomyelitis (a bone infection unresponsive to conventional management). Approved uses also include soft tissue and osteoradionecrosis (tissue damage resulting from prior radiation therapy) and progressive necrotizing infections like necrotizing fasciitis.
How Medicare Determines Coverage and Payment
Coverage for HBOT falls under Medicare Part B, which addresses outpatient medical services. For the treatment to be covered, it must meet the strict medical necessity criteria outlined in the national NCD 20.29. This means that a physician must provide a signed order and clinical records that clearly substantiate the diagnosis and the necessity of HBOT as a treatment.
The provider must submit documentation demonstrating the patient meets every specified criterion, such as the required Wagner grade or failure of standard therapy. If the national policy is not specific enough, Medicare Administrative Contractors (MACs) may issue Local Coverage Determinations (LCDs) to refine documentation and criteria. Continued coverage also depends on a demonstrated measurable sign of healing within any 30-day period of treatment. If the treatment is deemed medically necessary and meets all documentation requirements, Medicare Part B will pay 80% of the Medicare-approved amount.
Conditions Excluded from Medicare Coverage
Medicare explicitly lists conditions for which HBOT is considered experimental, investigational, or not medically necessary, preventing reimbursement for uses lacking sufficient clinical evidence. Conditions like cutaneous, decubitus, and stasis ulcers are not covered, even though they are types of non-healing wounds.
HBOT is also excluded for non-vascular causes of chronic brain syndrome (such as Alzheimer’s disease or senility). Other non-covered uses include:
- Treatment for multiple sclerosis.
- Certain arthritic diseases.
- Chronic peripheral vascular insufficiency.
Individuals seeking HBOT for these or any other non-approved conditions will be responsible for 100% of the treatment cost.
Patient Out-of-Pocket Costs
When HBOT treatment is approved and covered by Medicare Part B, the beneficiary is responsible for a portion of the cost. The patient must first meet the annual Part B deductible. After the deductible is met, the patient is responsible for a 20% coinsurance of the Medicare-approved amount for each HBOT session.
The cost of a single session can vary widely, but patients pay 20% of the final approved charge, not the billed charge. Medigap policies or Medicare Advantage plans may cover some or all of this 20% coinsurance, which can significantly reduce the patient’s financial responsibility.