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Medical Policy Revision: Hyperbaric Oxygen

Effective April 13, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider claims for hyperbaric oxygen therapy.

Based on the guidelines of our revised medical policy, Hyperbaric Oxygen, claims submitted for services provided April 13, 2015 and after that include CPT® code 99183 will be denied as an experimental /investigational service if submitted with one or more of the diagnosis codes listed below.

ICD-9 diagnosis codes:
040.0, 249.70, 249.71, 249.80,250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 285.1, 376.03, 707.05, 730.10, 730.11, 730.12, 730.13, 730.14, 730.15, 730.16, 730.17, 730.18, 730.19, 902.53, 903.01, 903.1, 904.0, 904.41, 909.2, 925.1, 925.2, 926.0, 926.11, 926.12,,926.19, 926.8, 926.9, 927.00, 927.01, 927.02, 927.03, 927.09, 927.10, 927.11, 927.20, 927.21, 927.3, 927.8, 927.9, 928.00, 928.01, 928.10, 928.11, 928.20, 928.21, 928.3, 928.8, 928.9, 929.0, 929.9, 958.0, 986,987.7, 989.0, 990, 993.3, 996.90, 996.91, 996.92, 996.93, 996.94, 996.95, 996.96, 996.99, 998.83, 999.1.

ICD-10 diagnosis codes:
A48.0, E08.52, E09.52, E13.52, E08.51, E08.621, E08.622, E09.621, E09.622, E13.621, E13.622, E11.52, E13.52, E10.52, E11.621, E11.622, E13.621, E13.622, E10.621, E10.622, D62, H05.021, H05.022, H05.023, H05.029, L89.95, M86.30, M86.40, M86.50, M86.60, M86.8x9, M86.311, M86.312, M86.319, M86.411, M86.412, M86.419, M86.511, M86.512, M86.519, M86.611, M86.612, M86.619, M86.8x1, M86.321, M86.322, M86.329, M86.421, M86.422, M86.429, M86.521, M86.522, M86.529, M86.621, M86.622, M86.629, M86.8x2, M86.331, M86.332, M86.339, M86.431, M86.432, M86.439, M86.531, M86.532, M86.539, M86.631, M86.632, M86.639, M86.8x3, M86.341, M86.342, M86.349, M86.441, M86.442, M86.449, M86.541, M86.542, M86.549, M86.641, M86.642, M86.649, M86.8x4, M86.351, M86.352, M86.359, M86.451, M86.452, M86.459, M86.551, M86.552, M86.559, M86.651, M86.652, M86.659, M86.8x5, M86.361, M86.362, M86.369, M86.461, M86.462, M86.469, M86.561, M86.562, M86.569, M86.661, M86.662, M86.669, M86.8x6, M86.371, M86.372, M86.379, M86.471, M86.472, M86.479, M86.571, M86.572, M86.579, M86.671, M86.672, M86.679, M86.8x7, M86.38, M86.48, M86.58, M86.68, M86.8x8, M86.39, M86.49, M86.59, M86.69, M86.8x0, S35.511A, S35.512A, S35.513A, S45.001A, S45.002A, S45.009A, S45.011A, S45.012A, S45.019A, S45.091A, S45.092A, S45.099A, S45.101A, S45.102A, S45.109A, S45.111A, S45.112A, S45.119A, S45.191A, S45.192A, S45.199A, S45.201A, S45.202A, S45.209A, S45.211A, S45.212A, S45.219A, S45.291A, S45.292A, S45.299A, S75.001A, S75.002A, S75.009A, S75.011A, S75.012A, S75.019A, S75.021A, S75.022A, S75.029A, S75.091A, S75.092A, S75.099A, S85.001A, S85.002A, S85.009A, S85.011A, S85.012A, S85.019A, S85.091A, S85.092A, S85.099A, L59.9, S07.0xxA, S07.1xxA, S07.8xxA, S07.9xxA, S17.0xxA, S17.8xxA, S17.9xxA, S38.001A, S38.002A, S38.01xA, S38.02xA, S38.03xA, S38.1xxA, S38.1xxA, S28.0xxA, S28.0xxA, S28.0xxA, S47.1xxA, S47.2xxA, S47.9xxA, S47.1xxA, S47.2xxA, S47.9xxA, S47.1xxA, S47.2xxA, S47.9xxA, S47.1xxA, S47.2xxA, S47.9xxA, S47.9xxA, S57.80xA, S57.81xA, S57.82xA, S57.00xA, S57.01xA, S57.02xA, S67.20xA, S67.21xA, S67.22xA, S67.30xA, S67.31xA, S67.32xA, S67.40xA, S67.41xA, S67.42xA, S67.90xA, S67.91xA, S67.92xA, S67.00xA, S67.01xA, S67.02xA, S67.10xA, S67.190A, S67.191A, S67.192A, S67.193A, S67.194A, S67.195A, S67.196A, S67.197A, S67.198A, S47.1xxA, S47.2xxA, S47.9xxA, S47.1xxA, S47.2xxA, S47.9xxA, S77.10xA, S77.11xA, S77.12xA, S77.00xA, S77.01xA, S77.02xA, S87.80xA, S87.81xA, S87.82xA, S87.00xA, S87.01xA, S87.02xA, S97.80xA, S97.81xA, S97.82xA, S97.00xA, S97.01xA, S97.02xA, S97.101A, S97.102A, S97.109A, S97.111A, S97.112A, S97.119A, S97.121A, S97.122A, S97.129A, S77.20xA, S77.21xA, S77.22xA, S77.20xA, S77.20xA, S77.20xA, T79.0xxA, T58.01xA, T58.02xA, T58.03xA, T58.04xA, T58.11xA, T58.12xA, T58.13xA, T58.14xA, T58.2x1A, T58.2x2A, T58.2x3A, T58.2x4A, T58.8x1A, T58.8x2A, T58.8x3A, T58.8x4A, T58.91xA, T58.92xA, T58.93xA, T58.94xA, T57.3x1A, T57.3x2A, T57.3x3A, T57.3x4A, T65.0x1A, T65.0x2A, T65.0x3A, T65.0x4A, T66.xxxA, T70.3xxA, T87.0x9, T87.1x9, T87.0x9, T87.0x9, T87.0x9, T87.0x1, T87.0x2, T87.0x9, T87.1x9, T87.1x1, T87.1x2, T87.1x9, T87.1x9, T87.2, T81.89xA, T80.0xxA.
 

Review this revised policy in our online Medical Policy Manual.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after April 13, 2015.

CPT®is a registered mark of the American Medical Association.

Published on: January 12, 2015, 08:00 a.m. ET
Last updated on: November 24, 2020, 23:27 p.m. ET