Indications for Hyperbaric Oxygen Therapy
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Almost all health care plans/third party payers reimburse for HBOT treatments performed on currently accepted disorders approved by the Hyperbaric Oxygen Therapy Committee of the Undersea and Hyperbaric Medical Society (UHMS). These indications are:
- Acute carbon monoxide poisoning
- Decompression illness (Bends)
- Gas embolism
- Gas gangrene
- Acute traumatic peripheral ischemia
- Crush injuries, suturing of severed limbs, compartment syndrome
- Progressive necrotizing fasciitis
- Acute peripheral arterial insufficiency
- Preparation and preservation of compromised skin grafts
- Chronic refractory osteomyelitis
- Cyanide poisoning
- Soft tissue radionecrosis
- Diabetic wounds of lower extremities
Summary of Covered Conditions
1. Acute carbon monoxide intoxication
Acute carbon monoxide intoxication induces hypoxic stress. Cardiac and central nervous systems are the most susceptible to injury from carbon monoxide. Administration of supplemental oxygen is essential treatment. HBO therapy causes a higher rate of dissociation of carbon monoxide from hemoglobin than occurs when breathing pure air at sea level pressure. Chamber compression should be between 2.5 and 3.0 atmosphere absolute (atm abs). It is not uncommon in patients with persistent neurological dysfunction to require subsequent treatments within six to eight hours, continuing once or twice daily, until there is no further improvement in cognitive functioning.
2. Decompression illness
Decompression illness arises when rapid decompression during ascent causes excess nitrogen gas bubble formation in tissue or blood, in volumes sufficient enough to interfere with the function of an organ or cause alteration in sensation. Clinical manifestations range from skin eruptions to shock and death. Circulating gas emboli may be heard with a Doppler device. The treatment of choice for decompression illness is HBO therapy with oxygen, or in unusual circumstances, with mixed gases. The result is immediate reduction in bubble volume. Treatment prescription is highly variable and case specific. Depths could range between 60 to 165 feet of seawater for durations of 1.5 to over 14 hours. The patient mayor may not require repeat dives.
3. Gas embolism
Gas embolism occurs when gases enter the venous or arterial vasculature, embolizing in a large enough volume to compromise function of an organ or body part. This occlusive process results in ischemia to the affected areas. Air emboli may occur as a result of surgical procedures (e.g., cardiovascular surgery, intraaortic balloons, arthroplasties or endoscopies), use of monitoring devices, (e.g., Swan-Ganz introducer or infusion pumps), traumatic injuries (e.g., gunshot wounds or penetrating chest injuries) or may occur in nonsurgical patients (e.g., diving, ruptured lung in respirator-dependent patient or injection of fluids into tissue space). HBO therapy is the treatment of choice for gas embolism and is most effective when initiated early. Therapy is directed toward reducing gas bubble volume and increasing the diffusion gradient of the embolized gas. The determination of an appropriate treatment profile (treatment pressure, duration, breathing gas mixture) is based on the specific needs of the patient and is the responsibility of the physician supervising hyperbaric oxygen treatment.
4. Gas gangrene
Gas gangrene is an infection caused by Clostridium bacillus, the most common being Clostridium perfringens. Clostridial myositis and myonecrosis (gas gangrene) is an acute, rapidly growing invasive infection of the muscle. It is characterized by profound toxemia, extensive edema, massive death of tissue, and variable degree of gas production. The most prevalent toxin is the alphatoxin, which itself is hemolytic, tissue necrotizing, and lethal. The diagnosis of gas gangrene is based on clinical data supported by a positive, Gram-stained smear obtained from tissue fluids. X-ray radiographs, if obtained, can visualize tissue gas.
The onset of gangrene may occur one to six hours after injury and presents with severe and sudden pain at the infected area. Skin overlying the wound progresses from shiny and tense to dusky, then bronze in color. The infection may progress as rapidly as six inches per hour and hemorrhagic vesicles may be noted. A thin, sweet odored exudate is present accompanied by swelling and edema. Affected muscle tissue progresses from dark red to black in color.
The acute challenge in treating gas gangrene is to stop rapidly advancing tissue destruction caused by alpha-toxin. Medical treatment is aimed at stopping the production of alpha-toxin, and to continue treatment until the advancement of the disease process has been arrested. The goal of HBO therapy is to inhibit growth of the anaerobic bacteria and the resulting production of alpha-toxin, at which point the body may use its own host defense mechanisms. HBO therapy starts as soon as the clinical picture presents and is supported by a positive, Gram-stained smear.
HBO therapy is used as an adjunct to antibiotic therapy and surgery. Usual treatment consists of oxygen administered at 3.0 atm abs pressure for 90 minutes or at sufficient pressure to achieve tissue oxygen pressures of greater than 400 mmHg, three times in the first 24 hours. Over the next four to five days, treatment sessions twice a day are usual. Timely initiation of HBO therapy yields better outcome in terms of life, limb and tissue preservation.
5. Acute traumatic peripheral ischemia
HBO therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened.
Acute traumatic peripheral ischemia (ATI) is the result of injury that compromises circulation to an extremity and places the extremity at risk for necrosis or amputation. Secondary complications, such as infection, nonhealing wounds and nonunited fractures are frequently observed. For acute traumatic peripheral ischemia, crush injuries and suturing of severed limbs, HBO therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures, when loss of function, limb or life is threatened.
The goal of HBO therapy is to enhance oxygenation at the tissue level to supportability. When tissue oxygen tension falls below 30 mm Hg., the body's ability to respond to infection and wound repair is compromised. HBO therapy benefits patients with AT! by enhancing tissue oxygenation, reducing edema and increasing oxygen delivery per unit of blood flow, thereby reducing the complication rates for infection, non-union and amputation.
The usual treatment schedule is three treatment periods of 1.5 hours each for each day of the first 48 hours. Additionally, two treatment sessions of 1.5 hours each for each day of the next 48 hours may be required. On the fifth and sixth days of treatment, one 1.5-hour session would typically be utilized. At this point in treatment, outcomes of restored perfusion, edema reduction and either /demarcation or recovery would be sufficient to guide discontinuing further treatments.
6. Crush injuries and suturing of severed limbs
As in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened.
7. Progressive necrotizing infections (necrotizing fasciitis)
For progressive necrotizing infections (necrotizing fasciitis) HBO therapy is recommended as an adjunct only in those settings where mortality and morbidity are expected to be high, despite aggressive standard treatment. Necrotizing fasciitis is a relatively rare, severe infection, and is usually a result of a group A streptococcal infection. It begins with severe or extensive cellulitis that spreads to involve the superficial and deep fascia, and produces thrombosis of the subcutaneous vessels and gangrene of underlying tissues. A cutaneous lesion usually serves as a portal of entry for the infection, but sometimes no such lesion is found. This covered indication does not include milder forms of Infection such as chronic ulcers with mild cellulitis.
8.Acute peripheral arterial insufficiency
As it is for acute traumatic ischemia, crush injuries and suturing of severed limbs, HBO therapy is also a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures, when loss of function, limb or life is threatened due to acute peripheral insufficiency. Arterial insufficiency ulcers may be treated by HBO therapy if they are persistent after reconstructive surgery has restored large vessel function. See the narrative in #5 above for additional information.
9. Preparation and preservation of compromised skin grafts(not for primary management of wounds…excludes artificial skin graft.)
Preservation of compromised skin grafts utilizes HBO therapy for graft or flap salvage in cases where hypoxia or decreased perfusion has compromised viability. HBO therapy enhances flap survival. Treatments are given at a pressure of 2.0 to 2.5 atm abs, lasting from 90-120 minutes. It is not unusual to receive treatments twice a day. When the graft or flap appears stable, treatments are reduced to daily. Should a graft or flap fail, HBO therapy may be used to prepare the already compromised recipient site for a new graft or flap. HBO therapy is not covered for the initial preparation of a skin graft site and is not considered medically necessary for the preservation of normal, uncompromised skin grafts or flaps.
10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management
Chronic refractory osteomyelitis is an infection in bone that persists or recurs, following appropriate interventions. Such interventions include the use of antibiotics, aspiration of abscess, immobilization of the affected extremity, and surgery. The Undersea and Hyperbaric Medical Society recommends that HBO therapy be used in patients with Cierny-Mader classification stage 3B and 4B osteomyelitis and in conjunction with the above medical and surgical treatments. (See Hyperbaric Oxygen Therapy: 1999 Committee Report.)
Antibiotics are chosen empirically or on the basis of bone culture and sensitivity studies. HBO therapy can elevate oxygen tension found in infected bone to normal or above-normal levels. This mechanism enhances healing and the body's own antimicrobial defenses. It is also believed that HBO therapy augments efficacy of certain antibiotics (e.g., gentamicin, tobramycin, and amikacin.)
The body's osteoclast function of removing necrotic bone is dependent on a proper oxygen-tension environment; HBO therapy provides this environment. HBO treatments for this condition are usually delivered at a pressure of 2.0 to 2.5 atm abs for durations of 90-120 minutes. It is not unusual to receive daily treatments following major debridement surgery. The number of treatments and the amount of pressure required vary on an individual basis. Medicare Part A can cover the use of HBO for chronic refractory osteomyelitis that has been demonstrated to be unresponsive to conventional medical and surgical management.
11. Osteoradionecrosis as an adjunct to conventional treatment
For osteoradionecrosis and soft tissue radionecrosis, HBO therapy is one part of an overall plan of care. Also included in this plan of care is debridement or resection of nonviable tissues, in conjunction with antibiotic therapy. Soft tissue flap reconstruction and bone grafting may also be indicated HBO therapy can be indicated both preoperatively and postoperatively in cases of radionecrosis.
Patients who suffer from severe soft tissue damage or bone necrosis present with disabling, progressive, and painful tissue breakdown. They may exhibit wound dehiscence, infection, tissue loss and graft or flap loss. The goal of HBO therapy is to increase the oxygen tension in both hypoxic bone and tissue to stimulate growth in functioning capillaries, fibroblastic proliferation, and collagen synthesis. Daily treatments may often last 90-120 minutes at 2.0 to 2.5 atm abs. The duration of HBO therapy is highly individualized.
12. Soft tissue radionecrosis as an adjunct to conventional treatment., See narrative in #11 above.
13. Cyanide poisoning
Cyanide poisoning carries a high risk of mortality. Victims of smoke inhalation frequently suffer from both carbon monoxide and cyanide poisoning. The traditional antidote for cyanide poisoning is the infusion of sodium nitrite. This treatment can potentially impair the oxygen- carrying capacity of hemoglobin. Using HBO therapy as an adjunct therapy adds the benefit of increased plasmadissolved oxygen. The HBO therapy protocol is to administer oxygen at 2.5 to 3.0 atm abs for up to 120 minutes during the initial treatment. Most patients with combination cyanide and carbon monoxide poisoning will receive only one treatment. The use of HBO therapy for treatment of pulmonary injury related to smoke inhalation per se remains experimental and is not covered by Medicare.
14. Actinomycosis only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment.
Actinomycosis is a bacterial infection caused by Actinomyces israelii. Its symptoms include slow-growing granulomas that later break down and discharge viscid pus containing minute, yellowish granules. Treatment includes prolonged antibiotic administration (penicillin and tetracycline). Surgical incision and draining of accessible lesions is also helpful.
Only after the disease process has been shown refractory to antibiotics and surgery, can HBO therapy be covered by Medicare.
15. Diabetic wounds of the lower extremities in patients who meet the following three criteria:
- Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
- Patient has a wound classified as Wagner grade III or higher; and
- Patient has failed an adequate course of standard wound therapy.
The use of HBG therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30-days of treatment with standard wound therapy and must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds includes: assessment of a patient's vascular status and correction of any vascular problems in the affected limb if possible, optimization of nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, appropriate offloading, and necessary treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBG therapy. Continued treatment with HBG therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. (Coverage for treatment of diabetic wounds that meet the above criteria is effective for dates of service on or after 4/1/03)