Loading...
Skip to content
Medicare Part [Change]
CMS Link
CMS Link

Hyperbaric Oxygen (HBO) Therapy Prior Authorization Request - Medical Record Checklist


To support medical necessity, medical records should contain at least the following information.


Actinomycosis

NOTE: The HBO therapy is covered only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment.

The medical records should:

Identify the location of the infection
Support the diagnosis of actinomycosis with a report of a diagnostic procedure.
Example: The results of sputum, pus or biopsy specimen cultures, etc.
Support the surgical incision and drainage of lesions.
Identify the prolonged administration of appropriate antibiotics.
Identify the conventional treatment/therapy the patient is receiving.

Chronic refractory osteomyelitis

NOTE: The HBO therapy is covered only when the condition is unresponsive to conventional medical and surgical management.

The medical records should:

Support an initial diagnosis of osteomyelitis with a report of a diagnostic procedure.
Example: Such as but not limited to: CT, MRI, or bone scan, etc.
Identify the conventional medical management to which the patient did not respond.
Identify the conventional surgical management to which the patient did not respond.
Support the diagnosis of chronic refractory osteomyelitis has been unresponsive to both medical and surgical management.

Diabetic wound to the lower extremity (DWLE)

NOTE: The patient must meet the following three criteria:
1. Patient has Type I or Type II diabetes and has a lower extremity wound that is due to diabetes.
2. Patient has a wound classified as Wagner grade III or higher.
3. Patent has no measurable signs of healing after completing 30 days of standard wound therapy as defined in the National Coverage Determination (NCD).

The medical records should:

Include an assessment of patient's vascular status and correction of vascular problems if possible.
Example: Such as but not limited to: ABI, toe signals, interventions performed by a vascular surgeon, etc.
Support optimization of nutritional status.
Example: Such as but not limited to: lab work, dietetic teaching, etc.
Support optimization of glucose control.
Example: Such as but not limited to: Hemoglobin A1c, serial glucose levels, etc.
Describe debridement to remove devitalized tissue.
Identify wound care management that includes maintenance of a clean, moist bed of granulated tissue with appropriate moist dressing.
Identify appropriate off-loading.
Identify treatment to resolve any infections.

Osteoradionecrosis

NOTE: The HBO therapy is covered only as an adjunct to conventional therapy.

The medical records should:

Identify the anatomical location, the reason, and the dates the treatment the radiation was received.
Support the diagnosis of osteoradionecrosis with a report of a diagnostic procedure.
Example: Such as but not limited to: X-ray CT, or MRI, etc.
Identify the conventional treatment/therapy the patient is receiving.

Soft tissue radionecrosis

NOTE: The HBO therapy is covered only as an adjunct to conventional therapy.

The medical records should:

Identify the anatomical location, the reason, and the dates the treatment the radiation was received.
Support the diagnosis of soft tissue radionecrosis with a report of a diagnostic procedure.
Example: Such as but not limited to: Visual examination or biopsy, CT, etc.
Identify the conventional treatment/therapy the patient is receiving.

Was this page helpful?
Last modified:  12/20/2016