`G0277` Hbot, full body chamber, 30m

Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

Medicare coverage: Special coverage instructions apply
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 5 units per day (clinical), rationale: Clinical: Data
Outpatient hospital: max 5 units per day (clinical), rationale: Clinical: Data

Medicare pricing for G0277

Physician Fee Schedule (CY 2026, RVU26D)

Status A: active, paid separately under the PFS if covered. National amounts: non-facility $193.73, facility $193.73 (total RVUs 5.80 / 5.80 × $33.4009 conversion factor; facility NA: rarely or never done in that setting). Work RVU 0.00, practice expense RVU 5.76 non-facility and 5.76 facility, malpractice RVU 0.04. Global period XXX. Qualifying APM participants are paid at a $33.5675 conversion factor.

Payer policies and prior authorization for G0277

56 of 56 payer prior-auth lists that name G0277 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Texas, Blue Shield of California, CarePlus Health Plans, Cigna, HealthSpring, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, and others.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross Blue Shield of Arizona (AZ Blue)	AZ Blue-administered Medicare Advantage (M2K)	AZ	prior auth required		Sep 1, 2026	AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Standard PA code list (most commercial plans)	AZ	prior auth required	Gold-card eligible	Sep 1, 2026	AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	State of Arizona employee group (SYD, S3Z)	AZ	prior auth required	Gold-card eligible	Sep 1, 2026	State of Arizona Group Prior Authorization Requirements Code List (09/01/2026)
Blue Shield of California	Blue Shield Medicare	CA	prior auth required		Sep 1, 2026	Prior Authorization List for Blue Shield Medicare
Blue Shield of California	Blue Shield commercial	CA	prior auth required		Sep 1, 2026	Prior Authorization List for Blue Shield
Aetna	Commercial	All	prior auth required		Oct 1, 2026	Participating provider precertification list for Aetna®
Cigna	ACA/IFP	All	prior auth required		Jan 1, 2015	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required		Jan 1, 2015	Master Precertification List (For Health Care Providers)
Blue Cross and Blue Shield of Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Jul 1, 2026	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
HealthSpring	Medicare Advantage	All	prior auth required		Jan 1, 2025	2026 Q4 Prior Authorization List
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana D-SNP (FL)	FL	prior auth required		Jan 1, 2027	1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
Humana	Humana D-SNP (IL)	IL	prior auth required		Jan 1, 2027	Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
Humana	Humana D-SNP (IN)	IN	prior auth required		Jan 1, 2027	*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
Humana	Humana D-SNP (MI)	MI	prior auth required		Jan 1, 2027	1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List
Humana	Humana D-SNP (SC)	SC	prior auth required		Jan 1, 2027	Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana Healthy Horizons	IL	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Illinois Prior Authorization and Notification List To view -specific medical coverage policies, please visit Humana Healthy Horizons in Illinois Clinical coverage policies .
Humana	Humana Healthy Horizons	IN	prior auth required		Jan 1, 2027	1 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a
Humana	Humana Healthy Horizons	OH	prior auth required		Jan 1, 2027	555201OH0924-B OHHMZG2EN Humana Healthy Horizons® in Ohio Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana Healthy Horizons	OK	prior auth required		Jan 1, 2027	Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana Healthy Horizons	VA	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL)
Humana	Humana MA and D-SNP	All	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana Puerto Rico MA and Dual Medicare-Medicaid	PR	prior auth required		Nov 3, 2025	Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
Humana	Oak Street Health	All	prior auth required			Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Molina Complete Care (Virginia)	Medicare-only PA matrix for D-SNP	VA	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022
Molina Complete Care (Virginia)	Medicaid	VA	prior auth required		Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of Arizona	Medicare-only PA matrix for D-SNP	AZ	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022
Molina Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of California	Medicare Advantage	CA	prior auth required		Jul 1, 2021	Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021
Molina Healthcare of Florida	Medicare Advantage	FL	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021
Molina Healthcare of Idaho	Medicaid	ID	prior auth required		Jan 1, 2025	Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of Idaho	Medicare Advantage	ID	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Jan 1, 2022	Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of Iowa	Medicaid	IA	prior auth required		Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Medicare Advantage	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Michigan	Exchange	MI	prior auth required		Jul 1, 2021	Molina Healthcare of Michigan PA Matrix, effective 7/1/2021
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required		Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of Nevada	Medicaid	NV	prior auth required		Oct 1, 2022	Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of New Mexico	Medicare Advantage	NM	prior auth required		Jan 1, 2021	Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021
Molina Healthcare of Ohio	Medicaid and MyCare Ohio (MMP) Medicaid	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Medicare and MyCare Ohio (MMP) Medicare	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Exchange	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of South Carolina	Medicare Advantage	SC	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021
Molina Healthcare of Texas	STAR	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of Texas	STAR+PLUS	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19
Molina Healthcare of Texas	STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)	TX	prior auth required		Jul 1, 2026	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
Molina Healthcare of Texas	Exchange	TX	prior auth required		Sep 1, 2019	Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
Molina Healthcare of Utah	Medicare Advantage	UT	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021
Molina Healthcare of Utah	Medicaid	UT	prior auth required		Jan 1, 2025	Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
Molina Healthcare of Washington	Medicare Advantage	WA	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021
Molina Healthcare of Wisconsin	Medicare Advantage	WI	prior auth required		Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021
Molina Healthcare, Inc. (national grid)	Molina national (MHI) Medicare grid	All	prior auth required		Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required		Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Rocky Mountain Health Plans	Rocky Mountain Medicare Advantage D-SNP	CO	prior auth required		Feb 1, 2025	Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025

Payer coverage policies that name G0277

G0277 appears in 23 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, Centene, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, 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)	covered if criteria are met	Apr 21, 2026	payer document
Aetna	Hypertrophic Scars and Keloids (0389) Dermal substitutes, Losartan ointment, Topical oxandrolone	not covered	May 28, 2026	payer document
Aetna	Infertility (0327) Vasodilators for women undergoing fertility treatment	not covered	Jul 16, 2026	payer document
Aetna	Lyme Disease and other Tick-Borne Diseases (0215)	not covered	Jul 21, 2026	payer document
Aetna	Parkinson's Disease (0307)	not covered	Feb 24, 2026	payer document
Aetna	Tinnitus Treatments (0406)	not covered	Jul 10, 2026	payer document
Aetna	Xerostomia: Selected Treatments (0302)	not covered	Apr 14, 2026	payer document
Anthem	Hyperbaric Oxygen Therapy (Systemic/Topical) (CG-MED-73)	covered if criteria are met	May 14, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Hyperbaric Oxygen Therapy (L.2.01.412)	covered if criteria are met		payer document
Blue Cross & Blue Shield of Rhode Island	Hyperbaric Oxygen Therapy MEDICAL COVERAGE POLICY \| 5	covered if criteria are met	Apr 15, 2026	payer document
Blue Cross Blue Shield of Massachusetts	Hyperbaric Oxygen Therapy (653)	listed, no stance		payer document
Centene	Hyperbaric Oxygen Therapy (CP.MP.27)	covered if criteria are met	Jan 1, 2019	payer document
Cigna	Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment (0447)	not covered	May 15, 2026	payer document
Cigna	Hyperbaric and Topical Oxygen Therapies (0053)	covered if criteria are met	May 15, 2026	payer document
Cigna	Infertility Services (0089)	unproven / investigational	Jun 15, 2025	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
Regence	Hyperbaric Oxygen Therapy (Medicine 14)	listed, no stance	Nov 1, 2025	payer document
UnitedHealthcare	Hyperbaric Oxygen Therapy and Topical Oxygen Therapy (2026T0632J)	listed, no stance	May 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2027: PA added, Humana
Mar 1, 2025: PA removed, Rocky Mountain Health Plans
Mar 1, 2025: PA removed, Rocky Mountain Health Plans

Medicaid fee-for-service

Prior authorization required or conditional in VA, WA, WV.

AZ: $86.48 (outpatient_hospital), effective Oct 1, 2021
IN: $132.86 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
MS: $104.50 (comprehensive), effective Jul 1, 2026
ND: $217.03 (physician), effective Aug 1, 2026
NE: $104.19 (physician, non-facility), effective Jul 1, 2026
OK: $161.83 (physician, non-facility), effective Jul 1, 2026
VA: $40.82 (medical), effective Jan 1, 2015
VT: $106.85 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $60.85 (outpatient_hospital_apc, Ambulatory Surgical Centers), effective Apr 1, 2026

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.

G0277 Hbot, full body chamber, 30m