Medically reviewed by Uri Gedalia, MD, FACS
Chief Medical Officer, TrufaMED Urgent Care & Concierge Medicine
Board-Certified, General Surgery
Last reviewed: September 2026
Long COVID remains one of the most clinically difficult conditions we treat. Patients arrive months after an initial infection with persistent fatigue, cognitive slowing, exercise intolerance, postural orthostatic tachycardia, sleep disturbance, and a sense that they are no longer themselves. The standard care toolkit is limited.
Hyperbaric oxygen therapy has accumulated meaningful evidence as an adjunctive intervention. This post summarizes the current research, our protocol, and what we are seeing in Miami patients.
The Research Landscape
The most-cited randomized trial on HBOT for long COVID is Zilberman-Itskovich et al. (2022) which showed meaningful improvements in cognitive function, fatigue, sleep, and psychiatric symptoms after a 40-session HBOT course at 2.0 ATA versus sham. Follow-up studies through 2024 and 2025 have added supporting data. The mechanism is plausible: improved tissue oxygenation, modulation of mitochondrial function, and effects on neuroinflammation are all consistent with what we observe.
The evidence is suggestive but not yet definitive. Trial sizes have been modest; sham-controlled designs are challenging because patients can often tell whether they are at pressure. The intervention is reasonable to consider in patients who have not responded to other approaches and who can commit to the time and cost.
Who Is A Candidate
- Adults with documented prior COVID infection
- Symptoms persisting beyond 12 weeks from acute illness
- Cognitive, fatigue, or autonomic symptoms as the dominant pattern
- Other reversible causes excluded (thyroid, B12, iron deficiency, sleep apnea, depression)
- Patient is willing and able to commit to 30 to 40 sessions over 8 to 12 weeks
- No contraindications to HBOT
Our Protocol
We start every long COVID patient with a comprehensive evaluation:
- Detailed symptom history including specific functional limitations
- Comprehensive lab panel: CBC, CMP, hsCRP, ferritin, vitamin D, B12, full thyroid, fasting insulin/HbA1c, hormones if indicated
- Cardiac evaluation with ECG; echo if any chest symptoms
- Autonomic screen including standing heart rate response (for POTS pattern)
- Sleep evaluation
- Mental health screen
If long COVID is the working diagnosis and HBOT is a reasonable next step, we discuss the protocol:
- 30 to 40 sessions over 8 to 12 weeks
- 1.5 to 2.0 ATA depending on patient tolerance and goals
- 60-minute sessions
- 3 to 5 sessions per week during the active phase
- Symptom and functional tracking at weeks 4, 8, and 12
- Continuation, taper, or discontinuation decision at week 12 based on response
What Patients Notice, and When
Most responders notice initial change around session 10 to 15. The first improvements tend to be sleep quality, mood, and a subjective sense of mental clarity. Energy and exercise tolerance often follow at sessions 20 to 30. Cognitive function on objective testing typically improves over the full course.
Non-responders exist. Roughly 20 to 30 percent of patients in our practice see little change after 20 sessions; we recommend discontinuation at that point and pursuit of other strategies.
Cost And Insurance
Long COVID is not an FDA-approved indication for HBOT. Insurance generally does not cover the treatment for this indication. Out-of-pocket cost for a 30-session course is typically $4,500 to $9,000 depending on the package.
We recommend patients commit to the full course before starting. Partial courses generate cost without enough sessions for benefit.
Combination With Other Interventions
Most patients on HBOT for long COVID are also doing other things: graded exercise rehabilitation, autonomic management for POTS if present, NAD+ IV therapy, sleep optimization, anti-inflammatory diet, and selected supplements. We coordinate all of this through the practice and the patient’s existing physicians.
Frequently Asked Questions
What is the evidence that HBOT works for long COVID?
Several randomized trials have shown improvements in cognition, fatigue, and quality of life. The evidence is suggestive but not yet definitive. It is reasonable as adjunct intervention for patients with persistent symptoms.
How many sessions do most patients need?
30 to 40 sessions over 8 to 12 weeks. Shorter courses have not shown the same benefit in published research.
Does insurance pay for this?
Generally no for the long COVID indication. We provide itemized documentation for patients who want to submit for out-of-network reimbursement, but coverage is unlikely.
Is HBOT safe?
Yes, when supervised by an appropriately trained team. The main contraindications are untreated pneumothorax, certain ear conditions, and certain medications. We screen at the initial visit.