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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.33 Hyperbaric Oxygen Therapy (HBOT) : Prior Authorization for HBOT
HBOT procedure codes 99183 and G0277 require prior authorization. Prior authorization requests submitted for procedure code G0277 must also include revenue code 413. When requesting prior authorization, providers should use the Special Medical Prior Authorization (SMPA) Request Form on the TMHP website at
Refer to:
Section 5: Fee‑for‑Service Prior Authorizations for detailed information about prior authorization requirements.
The prior authorization request must include documentation that supports medical necessity and is specific to each appropriate covered indication as listed in the following table:
30-Minute Intervals Allowed for Procedure Code G0277
Professional Sessions Allowed for Procedure Code 99183
Evidence that gas bubbles are detectable by ultrasound, Doppler or other diagnostics
Carbon monoxide poisoning - initial authorization
Carbon monoxide poisoning - one subsequent authorization
Evidence of central retinal artery occlusion with treatment initiated within 24 hours of the occlusion
Compromised skin grafts and flaps - initial authorization
Evidence the flap or graft is failing because tissue is/has been compromised by irradiation or there is decreased perfusion or hypoxia
Compromised skin grafts and flaps - one subsequent authorization
Crush injury, compartment syndrome and other acute traumatic ischemias
Diagnosis based on signs and/or symptoms of decompression sickness after a dive or altitude exposure
Diabetic foot ulcer -initial authorization
After at least 30 days of standard medical wound therapy, with a wound pO2 less than 40 mmHg AND wound classified as Wagner grade 3 or higher. *
Diabetic foot ulcer - two subsequent authorizations
Hgb less than 6.0 sustained secondary to hemorrhage, hemolysis, or aplasia, when the client is unable to be cross matched or refuses transfusion because of religious beliefs
Clostridial myositis and myonecrosis (gas gangrene)
Evidence of unsuccessful medical and/or surgical wound treatment and positive Gram-stained smear of the wound fluid
Necrotizing soft tissue infections - initial authorization
Evidence of unsatisfactory response to standard medical and surgical treatment and advancement of dying tissue
Necrotizing soft tissue infections - two subsequent authorizations
Delayed radiation injury (soft tissue and bony necrosis) -initial authorization
Delayed radiation injury - one subsequent authorization
Refractory osteomyelitis - initial authorization
Evidence of unsatisfactory clinical response to conventional multidisciplinary treatment
Refractory osteomyelitis - one subsequent authorization
Acute thermal burn injury - initial authorization
Partial or full thickness burns covering greater than 20% of total body surface area OR with involvement of the hands, face, feet or perineum
Acute thermal burn injury - three subsequent authorizations
Evidence of continuing improvement demonstrated by clinical response
Intracranial abscess - initial authorization
Adjunct to standard medical and surgical interventions when one or more of the following conditions exist:
Intracranial abscess - one subsequent authorization
Evidence of improvement demonstrated by clinical response and radiological findings
Procedure code 99183 is authorized according to the number of professional sessions (total HBOT treatments), and procedure code G0277 is authorized according to the number of 30-minute intervals of chamber time. The units in the columns for procedure codes 99183 and G0277 represent the maximum number of sessions and intervals that are allowed for that procedure code per authorization.
Limitations beyond those listed in the table above are considered experimental and investigational.
In emergency situations, the prior authorization request must be submitted no later than three business days after the date the service is rendered. Providers must not submit a claim until the prior authorization request has been approved. If the request has not been approved, the claim will be denied.

Texas Medicaid & Healthcare Partnership
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