A4575 Hyperbaric o2 chamber dispsTopical hyperbaric oxygen chamber, disposable
Status X: statutory exclusion, not paid under the PFS.
2 of 2 payer prior-auth lists that name A4575 require prior authorization or set conditions: UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of New York | NY | prior auth under conditions | Prior authorization is required only for the DME codes listed with a retail purchase or cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Connected (Texas MMP) | TX | prior auth required | Jan 1, 2015 | Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U |
A4575 appears in 17 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Shield of California, BlueCross BlueShield of South Carolina, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments (0788) | not covered | Nov 19, 2025 | payer document |
| Aetna | Autism Spectrum Disorders (0648) | not covered | Oct 2, 2025 | payer document |
| Aetna | Dysphagia Therapy (0625) | not covered | Sep 25, 2025 | payer document |
| Aetna | Facial Nerve Paralysis (0745) Kinesio taping | not covered | Oct 30, 2025 | payer document |
| Aetna | Hyperbaric Oxygen Therapy (HBOT) (0172) | not covered | Apr 21, 2026 | payer document |
| Aetna | Infertility (0327) Vasodilators for women undergoing fertility treatment | not covered | Jul 16, 2026 | payer document |
| Aetna | Parkinson's Disease (0307) | not covered | Feb 24, 2026 | payer document |
| Aetna | Skin and Soft Tissue Substitutes (0244) | not covered | Jul 29, 2026 | payer document |
| Anthem | Hyperbaric Oxygen Therapy (Systemic/Topical) (CG-MED-73) | not covered | May 14, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Hyperbaric Oxygen Therapy (L.2.01.412) | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Rhode Island | Hyperbaric Oxygen Therapy | not covered | Apr 15, 2026 | payer document |
| Blue Shield of California | | Hyperbaric Oxygen Therapy (2.01.04) | listed, no stance | payer document | |
| BlueCross BlueShield of South Carolina | Hyperbaric Oxygen Therapy (CAM 20104) 996.69 | Infection and inflammatory reaction due to internal prosthetic device, implant, and graft | listed, no stance | Mar 1, 2026 | payer document |
| Cigna | Hyperbaric and Topical Oxygen Therapies (0053) | covered if criteria are met | May 15, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Hyperbaric Oxygen (HBO2) Therapy (THE801.003) | listed, no stance | Jan 1, 2026 | payer document |
| Premera Blue Cross | Hyperbaric Oxygen Therapy (2.01.505) | listed, no stance | Apr 13, 2026 | payer document |
| UnitedHealthcare | Hyperbaric Oxygen Therapy and Topical Oxygen Therapy (2026T0632J) | listed, no stance | May 1, 2026 | payer document |
Prior authorization required or conditional in IN, NY, OH.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.