Baromedical Associates, LLC

HBOT for Failed Flap and Skin Graft

Preparation and preservation of compromised skin flaps and grafts utilizes HBO therapy for graft or flap salvage in cases where hypoxia or decreased perfusion has compromised viability acutely. This indication is not for primary management of wounds, maintenance of split thickness skin grafts or bioengineered skin substitutes placed on wounds or operative sites (Mohs). HBO therapy may improve composite graft survival in the immediate postoperative period when viability appears threatened due to a technical complication. It is not indicated to correct the mechanical complication but may be adjunctive therapy once the technical problem has been corrected and the graft is jeopardized by a reperfusion effect.


HBO therapy has not been found to be of significant benefit post 24 hours of warm ischemia or signs of compromise. Covered services require traditional construction of a pedicle or composite graft (flap) with confirmation of viability.


Bioengineered or allogeneic skin substitutes and traditional split thickness skin grafts placed for wound coverage do not meet CMS NCD 20.29 interpretation for coverage. HBO therapy is not considered reasonable and necessary for the initial preparation of the body site for a graft except as covered for other entities (radio necrosis, resistant osteomyelitis, neuropathic ulcers, etc.).


Treatments are given intensively initially for up to 72 hours followed by re-evaluation of the wound. It is not unusual to receive 2-3 treatments per day for up to 3 days post creation of the graft when viability appears threatened. When the graft appears stable, treatments are reduced to daily or discontinued. The number of sessions provided to enhance graft survival is not expected to exceed 20.