Insurance Coverage for Hyperbaric Oxygen Therapy in Acutely Compromised Tissues

Abstract

Background Beyond its indication for chronic wounds, hyperbaric oxygen therapy (HBOT) is an adjunct to managing acutely compromised grafts and flaps. Because physicians have reported challenges obtaining insurance coverage for HBOT, this cross-sectional analysis reviews policy requirements and presents an algorithm to enhance the odds of successful reimbursement. Methods We identified the 60 largest health insurers by market share and enrollment and collected their policies on HBOT. We then conducted a dual, blind extraction of policy details (e.g., continuing and prior authorization, documentation, treatment guidelines) and compiled these data into an insurance reimbursement algorithm to assist prescribing physicians. Results Fifty-three health insurers (88.3%) had policies on HBOT; 47.2% (n ¼ 25) required prior authorization, and 61.9% (n ¼ 13) required continuing authorization after a set number of HBOT sessions (median: 20 sessions, interquartile range [IQR]: 12–30 sessions). Thirty-eight (71.7%) permitted clinical judgment when defining flap or graft “compromise,” and 35.7% (n ¼ 15) considered any pressure greater than 1 atmosphere absolute to be “hyperbaric.” Twenty-two insurers (41.5%) outlined documentation requirements for HBOT reimbursement; the most often requested documentation were medical records (n ¼ 19, 86.4%), signs of healing (n ¼ 12, 54.5%), images (n ¼ 10, 45.5%), treatment goals (n ¼ 8, 36.4%), and dive parameters (n ¼ 5, 22.7%). Conclusion Most insured Americans are eligible for 12 sessions of HBOT; however, medical necessity must be established early and reconfirmed often to increase the likelihood of reimbursement. Additionally, prescribing physicians should be aware that insurers differ in their documentation, prior authorization, and continuing authorization requirements.