Hyperbaric Oxygen Therapy Medical Policy Updates

Harvard Pilgrim has updated our Commercial medical policy for hyperbaric oxygen therapy to clarify that while prior authorization is required for all outpatient hyperbaric oxygen therapy provided to Harvard Pilgrim Commercial members, it is not required for hyperbaric oxygen therapy provided in a pressurized chamber for the treatment of emergency conditions.

The updated policy outlines specific coverage criteria related to coverage of hyperbaric oxygen therapy related to emergent and non-emergent conditions. In addition, the following indications have been added as exclusions from coverage:

  • Autism Spectrum Disorder
  • Cerebral Palsy
  • Cutaneous, decubitus, and stasis ulcer
  • Dementia
  • Prophylaxis treatment for osteoradionecrosis
  • Wagner Grade 2 or lower diabetic foot ulcers

For complete information, please refer to the updated Hyperbaric Oxygen Therapy Medical Policy.

Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

Joseph O’Riordan,

Kristin Edmonston,
Production Coordinator