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This policy outlines the procedures and coverage criteria for Hyperbaric Oxygen Therapy (HBOT) as a systemic treatment that enhances oxygen delivery to tissues, supporting treatment for specific medical conditions. It specifies emergent and non-emergent conditions under which HBOT may be approved, including acute arterial gas embolism, carbon monoxide poisoning, non-healing ulcers, and radiation tissue injuries, while outlining absolute and relative contraindications.
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