Highmark Commercial Medical Policy - Pennsylvania
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:

*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:

**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:           

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.

 

Procedure Codes
33946, 33947, 33948, 33949, 33952, 33954, 33956, 33958, 33962, 33964, 33966, 33984, 33986, 33987, 33988, 33989


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.

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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: If you need these services, contact the Civil Rights Coordinator.

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.

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