TL;DR: The Centers for Medicare & Medicaid Services modified NCD 12, its national coverage determination for hyperbaric oxygen therapy, effective January 9, 2026. Here's what billing teams need to know.
This update to the CMS hyperbaric oxygen therapy coverage policy tightens the criteria your team must document and bill against. NCD 12 in the CMS Medicare system governs every facility and physician billing HBO therapy to Medicare beneficiaries — from wound care centers to hospital outpatient departments. The policy does not list specific CPT or HCPCS codes, but the covered and non-covered indications are highly specific, and billing against the wrong indication is a fast path to claim denial.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | Hyperbaric Oxygen Therapy — NCD 12 |
| Policy Code | NCD 12 |
| Change Type | Modified |
| Effective Date | January 9, 2026 |
| Impact Level | High |
| Specialties Affected | Wound care, vascular surgery, hyperbaric medicine, infectious disease, plastic surgery, radiation oncology, emergency medicine |
| Key Action | Audit every active HBO therapy patient against the 15 covered indications and confirm diabetic wound cases meet all three Wagner-grade criteria before billing |
CMS Hyperbaric Oxygen Therapy Coverage Criteria and Medical Necessity Requirements 2026
NCD 12 defines hyperbaric oxygen therapy as a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. That definition matters for billing: treatments that don't meet this definition — topical oxygen, for example — don't fall under this coverage policy at all.
Reimbursement under Medicare is limited to HBO therapy administered in a chamber, including single-person units. There are 15 covered conditions under NCD 12. Medical necessity documentation must tie directly to one of those 15 indications. If it doesn't, CMS will not pay.
The 15 Covered Indications
The following conditions qualify for Medicare HBO reimbursement under NCD 12:
| # | Covered Indication |
|---|---|
| 1 | Acute carbon monoxide intoxication |
| 2 | Decompression illness |
| 3 | Gas embolism |
| 4 | Gas gangrene |
| 5 | Acute traumatic peripheral ischemia (adjunctive treatment when loss of function, limb, or life is threatened) |
| 6 | Crush injuries and suturing of severed limbs (adjunctive, when loss of function, limb, or life is threatened) |
| 7 | Progressive necrotizing infections, including necrotizing fasciitis |
| 8 | Acute peripheral arterial insufficiency |
| 9 | Preparation and preservation of compromised skin grafts (not for primary wound management) |
| 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 — adjunctive only, when refractory to antibiotics and surgical treatment |
| 15 | Diabetic wounds of the lower extremities (see specific three-part criteria below) |
The diabetic wound indication is where most billing teams run into trouble. It has its own three-part medical necessity test, and all three criteria must be met simultaneously.
Diabetic Wound Coverage — All Three Criteria Required
CMS requires all of the following before HBO therapy qualifies for reimbursement on a diabetic wound:
| # | Covered Indication |
|---|---|
| 1 | Diagnosis: The patient has type I or type II diabetes with a lower extremity wound caused by diabetes. |
| 2 | Wound severity: The wound is classified as Wagner grade III or higher. |
| 3 | Treatment failure: The patient has failed an adequate course of standard wound therapy. |
Standard wound therapy is not loosely defined here. CMS specifies it includes: vascular status assessment and correction of vascular problems where possible, nutritional optimization, glucose control optimization, debridement of devitalized tissue, maintenance of a moist wound bed with appropriate dressings, off-loading, and infection management.
"Failure" means no measurable signs of healing for at least 30 consecutive days of standard wound care. This is a hard threshold — not a clinical judgment call. Document the 30-day window explicitly in the chart before initiating HBO therapy billing.
Ongoing Coverage Rules for Diabetic Wounds
Once HBO therapy starts on a diabetic wound, the coverage policy imposes ongoing medical necessity requirements. Wounds must be evaluated at least every 30 days during HBO treatment. If there are no measurable signs of healing within any 30-day treatment period, continued HBO therapy is not covered. This isn't a soft guideline — continued treatment without documented healing progress will not be reimbursed and creates recoupment risk.
This ongoing evaluation requirement is operationally demanding. Build it into your workflow before the effective date of January 9, 2026, not after.
CMS Hyperbaric Oxygen Therapy Exclusions and Non-Covered Indications
The policy is explicit: all conditions not listed in the covered section are non-covered. There is no gray area here, and no prior authorization workaround for excluded indications.
CMS calls out 12 conditions by name as specifically non-covered. These are worth knowing cold, because they're common clinical presentations that staff might assume are covered.
Non-covered conditions under NCD 12:
| # | Excluded Procedure |
|---|---|
| 1 | Cutaneous, decubitus, and stasis ulcers |
| 2 | Chronic peripheral vascular insufficiency |
| 3 | Anaerobic septicemia and infection other than clostridial |
| 4 | Skin burns (thermal) |
| 5 | Senility |
| 6 | Myocardial infarction |
| 7 | Cardiogenic shock |
| 8 | Sickle cell anemia |
| 9 | Acute thermal and chemical pulmonary damage, including smoke inhalation with pulmonary insufficiency |
| 10 | Acute or chronic cerebral vascular insufficiency |
| 11 | Hepatic necrosis |
| 12 | Aerobic septicemia |
The real risk here is wound care. Decubitus ulcers and stasis ulcers are explicitly excluded — but they sometimes present alongside diabetic wounds or peripheral arterial disease. Billing HBO for a pressure ulcer when the documented primary indication is a decubitus wound is a denial waiting to happen, regardless of what else is in the chart.
Train your clinical documentation team on this distinction. The ICD-10 code you submit needs to reflect a covered indication specifically.
Coverage Indications at a Glance
| Indication | Status | Notes |
|---|---|---|
| Acute carbon monoxide intoxication | Covered | |
| Decompression illness | Covered | |
| Gas embolism | Covered | |
| Gas gangrene | Covered | |
| Acute traumatic peripheral ischemia | Covered | Adjunctive only; loss of function/limb/life must be threatened |
| Crush injuries and suturing of severed limbs | Covered | Adjunctive only; loss of function/limb/life must be threatened |
| Progressive necrotizing infections (necrotizing fasciitis) | Covered | |
| Acute peripheral arterial insufficiency | Covered | |
| Compromised skin grafts — preparation and preservation | Covered | Not for primary wound management |
| Chronic refractory osteomyelitis | Covered | Must be unresponsive to conventional medical and surgical management |
| Osteoradionecrosis | Covered | Adjunctive to conventional treatment only |
| Soft tissue radionecrosis | Covered | Adjunctive to conventional treatment only |
| Cyanide poisoning | Covered | |
| Actinomycosis | Covered | Adjunctive only; must be refractory to antibiotics and surgical treatment |
| Diabetic wounds of lower extremities | Covered — with conditions | All three criteria required: type I/II diabetes, Wagner grade III+, failed standard wound therapy (30 consecutive days) |
| Cutaneous, decubitus, and stasis ulcers | Not Covered | Explicitly excluded |
| Chronic peripheral vascular insufficiency | Not Covered | Explicitly excluded |
| Anaerobic septicemia (non-clostridial) | Not Covered | Explicitly excluded |
| Thermal skin burns | Not Covered | Explicitly excluded |
| Senility | Not Covered | Explicitly excluded |
| Myocardial infarction | Not Covered | Explicitly excluded |
| Cardiogenic shock | Not Covered | Explicitly excluded |
| Sickle cell anemia | Not Covered | Explicitly excluded |
| Smoke inhalation with pulmonary insufficiency | Not Covered | Explicitly excluded |
| Acute or chronic cerebral vascular insufficiency | Not Covered | Explicitly excluded |
| Hepatic necrosis | Not Covered | Explicitly excluded |
| Aerobic septicemia | Not Covered | Explicitly excluded |
CMS Hyperbaric Oxygen Therapy Billing Guidelines and Action Items 2026
This policy has teeth. The 30-day documentation requirements on diabetic wounds, the hard exclusion list, and the ongoing monitoring obligations all create specific billing risk. Here's what to do before January 9, 2026.
| # | Action Item |
|---|---|
| 1 | Audit every active HBO therapy patient right now. Pull your current HBO caseload and confirm each patient's documented indication maps to one of the 15 covered conditions under NCD 12. Any patient without a clearly documented qualifying indication is a claim denial risk on every session billed after January 9, 2026. |
| 2 | Tighten diabetic wound documentation to the three-part test. Every diabetic lower-extremity wound case needs explicit documentation of: the diabetes type and causal relationship to the wound, the Wagner grade (III or higher), and the 30 consecutive days of failed standard wound therapy. If any of those three elements is missing from the record, your claim is vulnerable. |
| 3 | Build a 30-day wound evaluation trigger into your scheduling system. CMS requires evaluation at least every 30 days during HBO treatment for diabetic wounds. If a patient misses that evaluation, you're billing for sessions that won't survive a medical necessity audit. Set automated reminders in your EHR or practice management system before the effective date. |
| 4 | Train your coders on the explicit exclusion list. The 12 non-covered conditions aren't obscure. Decubitus ulcers, thermal burns, and peripheral vascular insufficiency come up constantly in wound care settings. A coder who doesn't know these are excluded by name under NCD 12 will cause denials and potential recoupment. |
| 5 | Confirm your diagnosis codes reflect covered indications precisely. NCD 12 does not list specific CPT or HCPCS codes. Your billing stands or falls on the ICD-10 diagnosis codes you submit. Work with your coders and clinicians to confirm the primary diagnosis code documents a covered indication — not a co-morbidity or secondary condition that appears on the exclusion list. |
| 6 | Review adjunctive therapy documentation for the relevant indications. Several covered conditions require HBO to be adjunctive — used in combination with accepted standard treatment. Crush injuries, acute traumatic peripheral ischemia, osteoradionecrosis, soft tissue radionecrosis, and actinomycosis all require documentation that HBO is supplementing other treatment, not replacing it. If that documentation is thin, fix it. |
| 7 | Talk to your compliance officer if you bill HBO in a wound care center or hospital outpatient department. The benefit categories under NCD 12 include both physician services and outpatient hospital services incident to a physician's service. If your organization bills across multiple benefit categories, the medical necessity documentation requirements apply across all of them. Your compliance officer should review your HBO billing protocols against this updated coverage policy before January 9, 2026. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Hyperbaric Oxygen Therapy Under NCD 12
The policy data for NCD 12 does not list specific CPT or HCPCS codes. This is common for older NCDs that predate granular code-level guidance.
Your hyperbaric oxygen therapy billing team should verify the applicable procedure codes — typically from the HBO therapy code range — with your Medicare Administrative Contractor (MAC). MACs may issue local coverage determinations (LCDs) that add code-level specificity on top of this NCD. Check with your MAC for any LCD that addresses HBO codes in your jurisdiction, and make sure your charge capture reflects the correct codes for both facility and professional billing.
Do not assume the absence of codes in this NCD means billing is unrestricted. The covered-indication list is the binding constraint. Code selection must support the documented indication.
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