Extracorporeal Membrane Oxygenation (ECMO) - Blue Cross Blue ...

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)
MED202.038
BlueReview POSTED DATE: 11/17/2003
EFFECTIVE DATE: 10/24/2003
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COVERAGE:
Extracorporeal Membrane Oxygenation (ECMO) may be considered medically
necessary for coverage in neonates, infants, and children with cardiac
or respiratory failure that is not expected to improve with
conventional medical management. (medications and mechanical
ventilation).
ECMO is considered medically necessary as an adjunct to (or in post)
lung transplantation for infants, children and adults.
ECMO for adult patients, other than in post lung transplant, is
considered experimental or investigational.
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DESCRIPTION:
ECMO is the use of a near total cardiopulmonary bypass on infants and
children suffering from severe heart and lung failure. It is used when
the condition is believed to be potentially reversible but has been
unresponsive to more conventional medical management including
medication and mechanical ventilation. ECMO supports the activities of
the heart and lungs until the organs can recover function. The
intervention is expected to be bridge therapy to function recovery and
is not curative. ECMO is usually continued for three to twenty-one
days depending on the severity of the infant or child’s condition. The
decision to discontinue ECMO is made when evaluation of lung shows
that oxygenation and carbon dioxide elimination can be safely
supported with a conventional ventilator. Most infants and children
require ECMO support for five to seven days but, the duration depends
upon the severity of the lung and/or heart disease.
“In lung transplantation, ECMO is utilized for respiratory support and
stabilization. Typically, lung transplantation for pulmonary
hypertension employs cardiopulmonary bypass with associated complete
systemic anticoagulation, uncontrolled allograft reperfusion and
aggressive ventilation. Intraoperative and prolonged post-operative
use of ECMO allows avoidance of these factors and earlier allograft
function recovery.”
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RATIONALE:
Current literature has expanded the age limits of ECMO from the use of
neonates only, to include infants over 30 days of age, and children
with cardiac and respiratory failure. These limits have been expanded
due to new technology within the ECMO system which limits the amount
of heparinization necessary, therefore, limiting the problems with
bleeding experienced in past studies. Research has shown that ECMO
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company*
Southwest Texas HMO, Inc.* d/b/a HMO Blue ® Texas
* Independent Licensees of the Blue Cross and Blue Shield Association

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)
MED202.038
BlueReview POSTED DATE: 11/17/2003
EFFECTIVE DATE: 10/24/2003
_____________________________________________________________________________
does not cure lung or heart disease, but that it provides support for
the infant or child to allow the organs to heal.
Current literature supports the use of ECMO for intra- and
postoperatively prolonged support of lung transplantation for
pulmonary hypertension. ECMO support provides excellent initial organ
function due to optimal controlled reperfusion and non aggressive
ventilation. This results in improved outcomes even in advanced forms
of pulmonary hypertension.
Current literature does not support ECMO for the treatment of cardiac
and/or respiratory failure in adult patients, (other than lung trans-
plantation). This documentation does not verify the same improvement
in post ECMO outcomes for adults, as has been shown with infants and
children. The decrease in heparinization and the improvements in ECMO
technology do not show a significant change in the tendency toward
bleeding and thrombus development in adult patients. Additional study
is needed.
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PRICING:
ECMO is paid as a separate service from pediatric and neonatal
critical care evaluation and management services.
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REFERENCES:
• “Extracorporeal Membrane Oxygenation,” BCBSA TEC Evaluation,
(May 1987) 74-82.
• Don, S.M. “ECMO indications and complications” Hospital Practice
(Office Edition) (1990 June 15) 143-57.
• Zwischenberger, J.B., Null, D., et al. “Neonatal extracorporeal
membrane oxygenation in Texas.” The Journal of Texas Medicine (Texas
Medicine) (1990 August) 86(8): 72-78.
• “Extracorporeal Membrane Oxygenation,” BCBSA Uniform Medical Policy
Manual, Medicine, (1994 March) 33960.0.
• Glassman, L.R., Keenan, R.J., et al. “Extracorporeal membrane
oxygenation as an adjunct treatment for primary graft failure in
adult lung transplant recipients.” Journal of Thoracic and
Cardiovascular Surgery (1995 September) 110(3): 723-7.
• Zenati, M., Pham, S.M., et al. “Extracorporeal membrane oxygenation
for lung transplant recipients with primary severe donor lung
dysfunction.” Transplant International (1996) 9(3): 227-30.
• Caron, E.A., Hamblet Berlandi, J.L. “Extracorporeal membrane
oxygenation.” Nursing Clinics of North America (1997 March) 32(1):
125-40.
• Bartlett, R.H. “Extracorporeal Life Support Registry Report 1995.”
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company*
Southwest Texas HMO, Inc.* d/b/a HMO Blue ® Texas
* Independent Licensees of the Blue Cross and Blue Shield Association

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)
MED202.038
BlueReview POSTED DATE: 11/17/2003
EFFECTIVE DATE: 10/24/2003
_____________________________________________________________________________
ASAIO (1997 January - February) 43(1): 104-7.
• Ball, J.W., Noon, G.P., et al. “Extracorporeal membrane oxygenation
for early graft dysfunction in lung transplantation: a case report.”
Journal of Heart and Lung Transplantation (1997 April) 16(4):468-
71.
• Trittenwein, G., Furst, G., et al. “Preoperative ECMO in congenital
cyanotic heart disease using the AREC system.” Annals of Thoracic
Surgery (1997 May) 63(5): 1298-1302.
• Peek, G.J., Firmin, R.K. “Extracorporeal membrane oxygenation for
cardiac support.” Coronary Artery Disease (1997 June) 8(6): 377-88.
• Kollla, S., Awad, S.S., et al, “Extracorporeal life support for 100
adult patients with severe respiratory failure. Annals of Surgery
(1997 Oct) 226(4):544-64 565-6
• Chan, C.Y., Chen, Y.S., et al. “Extracorporeal membrane oxygenation
support for single lung transplantation in a patient with primary
pulmonary hypertension.” Journal of Heart and Lung Transplantation
(1998 March) 17(3): 325-7.
• Darling, E.M., et al “Use of ECMO without the oxygenator to provide
ventricular support after Norwood Stage I procedures. Annals of
Thoracic Surgery (2001 February) 71(2): 735-6.
• Bennett, C.C., Johnson, A., Field, D.J., Elbourne, D. “UK
collaborative randomized trial of neonatal extracorporeal membrane
oxygenation: follow-up to age 4 years.” Lancet (2001 April 7)
357(9262): 1096-6.
• Singh, A.R., “Neonatal and pediatric extracorporeal membrane
oxygenation.” Heart Disease (2002 January – February) 4(1): 40-6.
• Mueller,X.M.,Tevaearai, H.T.,Horisberger,J., Godar,G., von
Segesser, L.K. “ECMO and Cardiopulmonary Support”. Review of
Medical Suisse
• Romande (2002 March) 122(3): 127-30.
• Pereszleny, A., et al “Bilateral lung transplantation with intra-
and postoperatively prolonged ECMO support in patients with
pulmonary hypertension.” European Journal of Cardio-Thoracic Surgery
(2002 May) 21(5): 858-63.
• Alpard, S.K, Zwischenberger, J.B. “Extracorporeal membrane
oxygenation for severe respiratory failure.” Chest Surgical Clinics
of North America (2002 May) 12(2): 355-78.
• Jacobson, J., “Nitric oxide: platelet protectant properties during
cardiopulmonary bypass/ECMO. Journal of Extra-Corporeal Technology
(2002 June) 34(2): 144-7.
• Sistino, J.J., Smyre, J.T., Patel, K. “Ventricular function
determination during extracorporeal membrane.” Journal of Extra-
Corporeal Technology (2002 June) 34(2): 148-50.
• Levi, D., et al “Use of assist devices and ECMO to bridge pediatric
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company*
Southwest Texas HMO, Inc.* d/b/a HMO Blue ® Texas
* Independent Licensees of the Blue Cross and Blue Shield Association

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)
MED202.038
BlueReview POSTED DATE: 11/17/2003
EFFECTIVE DATE: 10/24/2003
_____________________________________________________________________________
patients with cardiomyopathy to transplantation.” Journal of Heart
and Lung Transplantation (2002 July) 21(7): 760-70.
• Elbourne, D., Field, D., Mugford, M. “Extracorporeal membrane
oxygenation for severe respiratory failure in newborn infants.”
Cochrane Database System Review (2002) (1): CD001340.
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Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company*
Southwest Texas HMO, Inc.* d/b/a HMO Blue ® Texas
* Independent Licensees of the Blue Cross and Blue Shield Association