Section 405IAC5-28-11. Hyperbaric oxygen therapy

   (a) Medicaid reimbursement is available for hyperbaric oxygen (HBO) therapy for the following conditions:

(1) Acute carbon monoxide intoxication.

(2) Decompression illness.

(3) Gas embolism.

(4) Gas gangrene.

(5) Acute traumatic peripheral ischemia.

(6) Crush injuries and suturing of severed limbs; as in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened.

(7) Meleney ulcers; the use of hyperbaric oxygen in any other type of cutaneous ulcer is not covered.

(8) Acute peripheral arterial insufficiency.

(9) Preparation and preservation of compromised skin grafts.

(10) Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management.

(11) Osteoradionecrosis as an adjunct to conventional treatment.

(12) Soft tissue radionecrosis as an adjunct to conventional treatment.

(13) Cyanide poisoning.

(14) Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment.

(15) Acute cerebral edema.

  (b) Medicaid reimbursement is not available for therapy by HBO for the following conditions or services:

(1) Topical application of oxygen.

(2) Cutaneous, decubitus, and stasis ulcers.

(3) Chronic peripheral vascular insufficiency.

(4) Anaerobic septicemia and infection other than clostridial.

(5) Skin burns (thermal).

(6) Senility.

(7) Myocardial infarction.

(8) Cardiogenic shock.

(9) Sickle cell crisis.

(10) Acute thermal and chemical pulmonary damage, including smoke inhalation with pulmonary insufficiency.

(11) Acute or chronic cerebral vascular insufficiency.

(12) Hepatic necrosis.

(13) Aerobic septicemia.

(14) Nonvascular causes of chronic brain syndrome, including Pick's disease, Alzheimer's disease, and Korsakoff's disease.

(15) Tetanus.

(16) Systemic aerobic infection.

(17) Organ transplantation.

(18) Organ storage.

(19) Pulmonary emphysema.

(20) Exceptional blood loss anemia.

(21) Multiple sclerosis.

(22) Arthritic diseases.

  (c) Hyperbaric oxygen therapy shall be clinically practical and shall not be a replacement for other standard successful therapeutic measures. (Office of the Secretary of Family and Social Services; 405 IAC 5-28-11; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3356; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA)