Mathieu, et al. Transcutaneous oxymetry in hyperbaric medicine. In Oriani, Marroni, Wattel (Eds) Handbook on hyperbaric medicine, Springer, Berlin (BDR): 1996(686-698)

Diabetic wounds of the lower extremities in patients who meet the following three criteria:

A) Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;

B) Patient has a wound classified as Wagner grade III or higher; and

C) Patient has failed an adequate course of standard wound therapy.

The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.

For diabetic wounds of the lower extremity, the Wagner classification of the wound and the failure of an adequate course (at least 30 days) of standard wound therapy must be documented at the initiation of therapy:

A) Documentation must demonstrate an ulcer with bone involvement (osteomyelitis), or localized gangrene, or gangrene of the whole foot.

B) Documentation of standard wound care in patients with diabetic wounds per the NCD must include:

• assessment of a patient’s vascular status and documentation of correction of any vascular problems in the affected limb;
• documentation of optimization of nutritional status;
• documentation of optimization of glucose control;
• documentation of debridement by any means to remove devitalized tissue;
• documentation of maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings;
• documentation of efforts for appropriate off-loading; anddocumentation of necessary treatment to resolve any infection that might be present.

Usually the starting point for any DFU/Wagner III during a TCOM should be around 35mmHg - 50mmHg, that number should double or triple after the 10 minute O2 challenge.  If it starts our less than 35mmHg and does not respond after the O2 challenge they may need vascular intervention.  Also, if you can do "in-chamber" TCOMS, do them, they are very helpful.