Extracorporeal Membrane Oxygenation Therapy (ECMO)

Coverage decision: Covered with conditions

Conditions of Coverage:

All procedures must be performed at a facility participating in the Extracorporeal Life Support Organization (ELSO) case registry.*

ECMO is allowed only:

  • In patients with severe life-threatening, but potentially reversible, acute respiratory or cardiac dysfunction unresponsive to conventional management, or
  • As a bridging therapy for patients in pulmonary failure who are on a pulmonary transplant list, or
  • As a bridging therapy for patients in cardiac failure who are eligible for a ventricular assist device or cardiac transplantation.

Background Information

This technology was reviewed by the State Health Technology Clinical Committee (HTCC) in March 2016 and the determination was finalized on May 20, 2016. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that ECMO is a covered benefit with conditions. Complete information on this HTCC determination is available at: http://www.hca.wa.gov/about-hca/health-technology-assessment/health-technology-reviews.

In adopting this HTCC coverage determination, the department has concluded that the determination does not conflict with any state statute applicable to L&I. Any coverage for humanitarian or investigational treatment would be considered per WAC 296-20-02850.

Implementation of the Coverage Decision

All requests for ECMO require authorization. The service may be covered only for care of a condition accepted on or related to the claim.

For billing information, please refer to L&I Fee Schedules and Payment Policies (MARFS).

For State Fund Claims

Please contact Utilization Review Vendor (Comagine): http://www.lni.wa.gov/ClaimsIns/Providers/AuthRef/UtilReview/default.asp

For Self-Insured Claims

Please contact the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIE/TPAs, go to: http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp

* The Extracorporeal Life Support Organization (ELSO) is an international non-profit consortium of health care institutions who are dedicated to the development and evaluation of novel therapies for support of failing organ systems. The primary mission of the Organization is to maintain a registry of, at least, use of extracorporeal membrane oxygenation in active ELSO centers. You may find active ELSO centers in Washington State or other States here

 

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