Insurance Coverage for Hyperbaric Oxygen Therapy in Acutely Compromised Tissues

Area of Science:

• Medical policy analysis
• Health services research

Background:

• Hyperbaric oxygen therapy (HBOT) is an established treatment for chronic wounds and an adjunct for managing compromised grafts and flaps.
• Physicians encounter challenges in securing insurance coverage for HBOT, necessitating a clearer understanding of payer requirements.

Purpose of the Study:

• To analyze insurance policies for HBOT reimbursement for grafts and flaps.
• To develop an algorithm to assist physicians in obtaining successful insurance coverage for HBOT.

Main Methods:

• Cross-sectional analysis of policies from the 60 largest health insurers.
• Dual, blind extraction of policy details including authorization, documentation, and treatment guidelines.
• Compilation of data into an insurance reimbursement algorithm.

Main Results:

• Of 53 analyzed insurers, 88.3% had HBOT policies; 47.2% required prior authorization and 61.9% required continuing authorization.
• Insurers varied in defining "compromise" (71.7% allowed clinical judgment) and "hyperbaric" pressure (35.7% defined it as >1 atm).
• Documentation requirements were outlined by 41.5% of insurers, most commonly medical records (86.4%), signs of healing (54.5%), and images (45.5%).

Conclusions:

• Most insured individuals are eligible for 12 HBOT sessions, but consistent demonstration of medical necessity is crucial for reimbursement.
• Physicians must be aware of differing insurer requirements for documentation, prior, and continuing authorization to optimize HBOT coverage.