| Printer Friendly Version |
| Medical Policy: | G-44-001 |
| Topic: | Extracorporeal Membrane Oxygenation (ECMO) for Adult Conditions |
| Section: | Miscellaneous |
| Effective Date: | July 2, 2018 |
| Issue Date: | July 2, 2018 |
| Last Reviewed: | February 2018 |
Extracorporeal membrane oxygenation (ECMO) provides extracorporeal circulation and physiologic gas exchange for temporary cardiorespiratory support in cases of severe respiratory and cardiorespiratory failure. ECMO is used in clinical situations in which there is respiratory or cardiac failure in which death would be imminent unless medical interventions can immediately reverse the underlying disease process, or physiologic functions can be supported for long enough that normal reparative processes or treatment can occur (e.g., resolution of acute respiratory distress syndrome, treatment of infection) or other life-saving intervention can be delivered (e.g. provision of a lung transplant). Potential indications for ECMO in adults include acute, potentially reversible respiratory failure due to a variety of causes; as a bridge to lung transplant; in potentially reversible cardiogenic shock; and as an adjunct to cardiopulmonary resuscitation (ECMO-assisted cardiopulmonary resuscitation [ECPR]). |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
The use of ECMO in adults may be considered medically necessary for the management of acute respiratory failure when ALL of the following criteria are met:
- Respiratory failure is due to a potentially reversible etiology; and
- Respiratory failure is severe, as determined by EITHER of the following:
- A standardized severity instrument such as the Murray score (see table attachment); or
- ONE of the following criteria for respiratory failure severity:
- Uncompensated hypercapnia with a pH less than 7.2; or
- PaO2/FIO2 of less than 100 mm Hg on fraction of inspired oxygen (FIO2) greater than 90%; or
- Inability to maintain airway plateau pressure (Pplat) less than 30 cm H20 despite a tidal volume of four (4) to six (6) mL/kg ideal body weight; or
- Oxygenation Index* greater than 30: or
- CO2 retention despite high Pplat (greater than 30 cm H2O).
*Oxygenation Index = FIO2 x 100 x MAP/PaO2 mm Hg (where FIO2 x 100 = FIO2 as percentage; MAP = mean airway pressure in cm H2O; PaO2 = partial pressure of oxygen in arterial blood).
AND
NONE of the following contraindications is present:
- High ventilator pressure (peak inspiratory pressure greater than 30 cm H2O) or high fraction of inspired oxygen (greater than 80%) ventilation for more than 168 hours; or
- Signs of intracranial bleeding; or
- Multisystem organ failure; or
- Prior (i.e. before onset of need for ECMO) diagnosis of a terminal condition with expected survival less than six (6) months; or
- A do-not-resuscitate directive; or
- Cardiac decompensation in an individual who has already been declined for ventricular assist device or transplant; or
- Known neurologic devastation without potential to recover meaningful function; or
- Determination of care futility**
**Assessment of ECMO futility:
Patients undergoing ECMO treatment should be periodically reassessed for clinical improvement. ECMO should not be continued indefinitely if the ANY of the following criteria are met:
- Neurologic devastation as defined by the following:
- Consensus from two (2) attending physicians that there is no likelihood of an outcome better than “persistent vegetative state” at six (6) months; and
- At least one of the attending physicians is an expert in neurologic disease and/or intensive care medicine; and
- Determination made following studies including computed tomography, electroencephalography, and exam; or
- Inability to provide aerobic metabolism, defined by the following:
- Refractory hypotension and/or hypoxemia; or
- Evidence of profound tissue ischemia based on creatine phosphokinase or lactate levels, lactate-to-pyruvate ratio, or near-infrared spectroscopy; or
- Presumed end-stage cardiac or lung failure without “exit” plan (i.e. declined for assist device and/or transplantation).
The use of ECMO in adults may be considered medically necessary as a bridge to heart, lung, or combined heart-lung transplantation for the management of respiratory, cardiac, or combined cardiorespiratory failure refractory to optimal conventional therapy.
The use of ECMO in adults is considered experimental/investigational when the above criteria are not met, including but not limited to acute and refractory cardiogenic shock and as an adjunct to cardiopulmonary resuscitation.
SEE table attachment for more information. |
| Place of Service: Inpatient |
Experimental/Investigational (E/I) services are not covered regardless of place of service.
| The policy position applies to all commercial lines of business |
| Denial Statements |
Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
| Links |
- Link to Provider Resource Center for the Medical Policy Update
04/2018: Coverage Criteria Established for Extracorporeal Membrane Oxygenation (ECMO) for Adult Conditions
 |
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
