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HBO Treatment Indication With Protocol

HBO Treatment Indication With Protocol

HBO Treatment Indication With Protocol

INTRODUCTION

The purpose of this topic is to provide practitioners of Hyperbaric Oxygen Therapy (HBO) an in-depth summary of HBO indications and common HBO treatment protocols. For an introduction to HBO, refer to An Introduction to Hyperbaric Oxygen Therapy

Treatment Protocol Guidelines

The following hyperbaric medicine treatment protocols are based upon the recommendations of the Hyperbaric Oxygen Committee of the Undersea and Hyperbaric Medical Society.  Clinical protocols and/or practice guidelines are systematically developed statements that help physicians, other practitioners, case managers and clients make decisions about appropriate health care for specific clinical circumstances.  

Protocols allow health providers to offer evidence-based, appropriate, standardized diagnostic treatment and care services to patients undergoing hyperbaric therapy.  Evidenced-based medicine offers clinicians a way to achieve improved quality, improved patient satisfaction, and reduced costs.  Utilization Review should be initiated when clinical decisions result in deviation from or modification of treatment protocols.  This includes any course of treatment at or above the recognized threshold limits. 

Medical Necessity

Medicare.gov defines “medically necessary” as “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” 

The following conditions meet coverage indications per the National Coverage Determination (NCD) 20.29.[1] Continued HBO therapy without documented evidence of effectiveness does not meet the Medicare definition of medically necessary treatment. Thorough re-evaluation should be made at least every 30 days for documentation of response to therapy. 

HBO INDICATIONS

By Indication

See all indications below in "Evidence-based indications accepted by the UHMS, approved by Medicare" and "Evidence-based indications accepted by the UHMS, NOT approved by Medicare"

By Treatment Protocol

Table 1: 90 minutes of oxygen breathing at 2 ATA without air break 

Table 1 based on Kindwall and Whelan [2] and National Baromedical Services [3]


Indications:         


Table 2: 90 minutes of oxygen breathing at 2 ATA with air break 

(patients with high seizure risk)


Table 2 based on Kindwall and Whelan [2] and National Baromedical Services [3]

Indications:

Table 3: 90 minutes oxygen breathing at 2.5 ATA with 2 air breaks 


Table 3 based on Kindwall and Whelan [2] and National Baromedical Services [3]

Indications:        

Table 4a: 90 minutes oxygen breathing at 3 ATA with 2 air breaks


Table 4a based on Kindwall and Whelan [2] and National Baromedical Services [3]

Indications:

Topics

Sample Physician Order

HBO request requirements checklist and sample EMR documentation

  Acute Carbon Monoxide Poisoning

 

-

  Clostridial Myonecrosis (Gas Gangrene)

 

-

Table 4b: Weaver Protocols for Carbon Monoxide Poisoning 


Table 4b based on Weaver et al [4]

Table V


Adapted from the U.S. Navy Diving Manual  [5]

  1. Descent Rate – 20 ft/min.
  2. Ascent Rate – Not to exceed 1 ft/min. Do not compensate for slower ascent rates. Compensate for faster rates by halting the ascent.
  3. Time on oxygen begins on arrival at 60 feet.
  4. If oxygen breathing must be interrupted because of CNS Oxygen Toxicity, allow 15 minutes after the reaction has entirely subsided and resume schedule at point of interruption
  5. Treatment Table may be extended two oxygen-breathing periods at the 30-foot stop. No air break required between oxygen-breathing periods or prior to ascent.
  6. Tender breathes 100% O2 during ascent from the 30-foot stop to the surface. If the tender had a previous hyperbaric exposure in the previous 12 hours, an additional 20 minutes of oxygen breathing is required prior to ascent.

Note: In a hyperbaric monoplace chamber operating on psi measurements, decompress at a rate of: 1 psi/2 min

  • 30 fsw = 13.3 psi (1.9 ATA)
  • 60 fsw = 26.7 psi (2.8 ATA)

Table VI

Adapted from the U.S. Navy Diving Manual [5]

  1. Descent Rate – 20 ft/min.
  2. Ascent Rate – Not to exceed 1 ft/min. Do not compensate for slower ascent rates. Compensate for faster rates by halting the ascent.
  3. Time on oxygen begins on arrival at 60 feet.
  4. If oxygen breathing must be interrupted because of CNS Oxygen Toxicity, allow 15 minutes after the reaction has entirely subsided and resume schedule at point of interruption
  5.  Table 6 can be lengthened up to 2 additional 25-minute periods at 60 feet (20 minutes on oxygen and 5 minutes on air), or up to 2 additional 75-minute periods at 30 feet (15 minutes on air and 60 minutes on oxygen), or both.
  6. Tender breathes 100% O2 during the last 30 minutes at 30 fsw and during ascent to the surface for an unmodified table or where there has been only a single extension at 30 or 60 feet. If there has been more than one extension, the O2 breathing at 30 feet is increased to 60 minutes. If the tender had a hyperbaric exposure within the past 12 hours, an additional 60-minute O2 period is taken at 30 feet.

Note:  In a hyperbaric monoplace chamber operating on psi measurements, decompress at a rate of: 1 psi/2 min

  • 30 fsw = 13.3 psi (1.9 ATA)
  • 60 fsw = 26.7 psi (2.8 ATA)

By Threshold Level

For a separate view of the table below, along with the treatment tables, see  HBO Threshold Levels

Indications

Threshold Levels

 

Lower Limit

Upper Limit / Utilization Review

Elective - Chronic

   

Chronic Refractory Osteomyelitis

20*

30-40‡

Diabetic Ulcer Lower Extremity

14

40

Intracranial Abscess

5

20‡

Late Radiation Tissue Injury Prophylaxis

20*

30‡

Mandibular Osteoradionecrosis

30*

60‡

Preparation of Wounds for Grafting

10

30‡

Problem Wound Support

14

30‡

Soft Tissue Radionecrosis

20*

60‡

Emergent – Acute

   

Acute Carbon Monoxide Poisoning

 

5‡

Acute Exceptional Blood Loss Anemia

Until satisfactory hematocrit or pt. stable, asymptomatic, 

or transfusion becomes possible

Acute Peripheral Ischemia/Crush Injury

3*

14‡

Acute Retinal Artery Insufficiency

 

**‡

Acute Thermal Burns

5*

30‡

Cerebral Arterial Gas Embolism

 

10‡

Clostridial Myonecrosis (Gas Gangrene)

5*

10‡

Compromised Skin Grafts and Flaps

6*

20‡

Decompression Sickness

 

10‡

Necrotizing Soft Tissue Infections

5*

30‡

Reattachment Limb/Digits

5

30

Selected Invasive Fungal Infections

7

20

Idiopathic Sudden Sensorineural Hearing loss 1 20

      *   If the patient receives less than the indicated lower treatment threshold, a case audit is to be undertaken. For these disorders, too few treatments may be unlikely to have sufficient therapeutic effect and potentially waste resources. Reasons for early termination of HBO therapy may include: death; misdiagnosis; non-compliance; deterioration, or failure to perceive improvement.

  **   For patients treated more than three days after clinical plateau.

  ‡   Recommendations of the Undersea and Hyperbaric Medical Society, Hyperbaric Oxygen therapy Indications 13th Edition, 2014.

HYPERBARIC CPT CODES

  • 99183 Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session (PROFESSIONAL CHARGE)
  • G0277 Hyperbaric oxygen under pressure, full body chamber, per 30 minute intervaL (FACILITY CHARGE)

TREATMENT

Evidence-based indications accepted by the UHMS, approved by Medicare

Elective – Chronic Indications

Emergent/Urgent – Acute Indications

Evidence-based indications accepted by the UHMS, NOT approved by Medicare

Elective – Chronic Indications

Emergent/Urgent – Acute Indications

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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

REFERENCES

  1. CMS. National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29) . Date of publication 2017;.
  2. Harry T. Whelan, Eric Kindwall et al. Hyperbaric Medicine Practice 4th Edition Best Publishing Company. Date of publication 2017;volume fourth():.
  3. National Baromedical Services. Introduction to Hyperbaric Medicine Primary Training Manual .;.
  4. Weaver LK, Hopkins RO, Chan KJ, Churchill S, Elliott CG, Clemmer TP, Orme JF Jr, Thomas FO, Morris AH et al. Hyperbaric oxygen for acute carbon monoxide poisoning. The New England journal of medicine. Date of publication 2002;volume 347(14):1057-67.
  5. U.S. Navy. Chapter 17. Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism in U.S. Navy Diving Manual , 7th ed. . Date of publication 2017;.
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SUBTOPICS