Insurance coverage for hyperbaric oxygen therapy in acutely compromised tissues

Authors: Heron MJ, Zhu KJ, McVeigh AB, Rezwan SK, Cooney CM, Broderick KP

Affiliation: Dept. of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland

Journal: Journal of Reconstructive Microsurgery. March 2026

PMID: 40505695

Key takeaways

• This cross-sectional analysis of U.S. insurer policies found that, among the 53 insurers with explicit HBOT coverage policies, nearly half required prior authorization and many also required continuing authorization.

• Coverage variability was driven less by whether HBOT was recognized and more by how compromise, hyperbaric treatment, documentation, and reassessment thresholds were defined.

• To maximize coverage, clinicians should document medical necessity early, rule out or correct mechanical causes, include objective healing data when possible, and anticipate frequent reauthorization requests.

Background

HBOT is a recognized, covered indication for compromised skin grafts and flaps under Medicare, but the supporting clinical literature remains narrower than many surgeons assume. That combination likely explains why coverage often exists but authorization requirements remain stringent and heterogeneous.

Objective

To characterize HBOT coverage requirements among major U.S. insurers for acutely compromised flaps and grafts and to build a practical authorization and documentation algorithm for prescribing surgeons.

Methods

• Design: Cross-sectional policy review with dual, blinded data extraction.

• Sampling frame: The 60 largest health insurers by market share and enrollment, capturing approximately 80% of the market nationally and within each state.

• Policy collection: Policies were gathered in August 2023 from public sources or directly from insurers when possible.

• Primary focus: Documentation requirements for HBOT reimbursement in compromised flaps and grafts.

• Secondary focus: Prior authorization, continuing authorization, treatment protocol requirements, credentialing, and pressure or session thresholds.

• Practical output: A surgeon-facing reimbursement algorithm.

Results

• Of 60 eligible insurers, 53 had explicit HBOT policies.

  • 49 covered HBOT to varying extents.

  • 3 labeled it investigational for compromised flaps or grafts.

  • 1 explicitly did not cover it.

  • 7 had no accessible confirmable policy.

• Prior authorization was required by 25 of 53 insurers.

• Only 15 insurers explicitly defined tissue compromise; most others relied on clinician judgment.

• Four policies required objective hypoxia with TcPO2 below 40 mmHg.

• Only 7 policies specified an actual treatment protocol, generally aligning with 2.0 to 2.5 ATA for 90 to 120 minutes, often twice daily initially.

• Documentation requirements were explicitly listed by 22 insurers.

  • Most commonly requested items included medical records, evidence of healing, wound images, treatment goals, anticipated duration, and dive parameters.

• Many insurers wanted documentation of diagnosis, flap or graft type, surgeon name, exclusion or correction of mechanical causes, and failure of conservative therapy.

• Continuing authorization was a major operational issue.

  • Session-based renewal thresholds clustered at 12, 15, 20, 30, and 40 sessions.

  • Twenty sessions was the median among policies using a session threshold.

• When two dives were performed in one day, each dive generally needed to be documented and billed separately.

Conclusion

Most major U.S. insurers recognize HBOT for compromised flaps and grafts, but approval depends heavily on how well the surgeon demonstrates medical necessity and ongoing response to treatment. The paper’s main contribution is not proving HBOT works biologically, but showing surgeons how to navigate the payer process quickly enough for HBOT to remain clinically useful in an acute salvage setting.

Strengths

• Addresses a highly practical coverage question that most HBOT papers do not.

• Broad insurer sampling designed to reflect the real U.S. market.

• Dual, blinded extraction improves reliability for a descriptive policy study.

• Provides an immediately usable reimbursement algorithm.

Limitations

• Policies were collected in 2023, so some requirements may already have changed.

• Published policies may not reflect actual claims behavior or hidden payer requirements.

• It does not include a formal cost-effectiveness analysis.

Clinical relevance

Most large insurers recognize the indication, but reimbursement depends on rapid, comprehensive documentation.

• Rule out mechanical causes of flap or graft compromise and document that clearly.

• Frame requests as acute flap or graft compromise rather than vague poor healing.

• Include operative notes, current findings, treatment goals, dive details, serial photos, and measurable improvement.

• Expect early reauthorization and plan reassessment accordingly.