The use of extracorporeal membrane oxygenation (ECMO) may be considered medically necessary for the management of adults with acute respiratory failure when all of the following criteria are met:
Respiratory failure is due to a potentially reversible etiology (see Policy Guidelines section) AND
Respiratory failure is severe, as determined by one of the following:
A standardized severity instrument such as the Murray score (see Policy Guidelines section); OR
One of the criteria for respiratory failure severity outlined in the Policy Guidelines. AND
None of the following contraindications are present:
High ventilator pressure (peak inspiratory pressure >30 cm H2O) or high fraction of inspired oxygen (>80%) ventilation for more than 168 hours;
Signs of intracranial bleeding;
Multisystem organ failure;
Prior (ie, before onset of need for ECMO) diagnosis of a terminal condition with expected survival less than 6 months;
A do-not-resuscitate directive;
Cardiac decompensation in a patient who has already been declined for ventricular assist device or transplant;
Known neurologic devastation without potential to recover meaningful function;
Determination of care futility (see Policy Guidelines section).
The use of ECMO may be considered medically necessary as a bridge to heart, lung, or combined heart-lung transplantation for the management of adults with respiratory, cardiac, or combined cardiorespiratory failure refractory to optimal conventional therapy.
The use of ECMO is considered 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.
