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    v1.0.30
    OpenPayerPolicy UpdatesVascular/Cardiothoracic SurgeryAmbetter Nevada ECMO Coverage Policy | OpenPayer
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    CurrentAmbetter NevadaPolicy WA.CP.MP.514

    Extracorporeal Membrane Oxygenation Therapy

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    This policy establishes medical-necessity criteria for ECMO therapy, including qualifying acute respiratory or cardiac dysfunction and bridge-to-transplant or bridge-to-device indications. Covered procedures must be performed at an ELSO case-registry-participating facility.

    Policy Summary
    PayerAmbetter Nevada
    PolicyExtracorporeal Membrane Oxygenation Therapy
    Policy CodePolicy WA.CP.MP.514
    Change TypeAnnual reviewreferences and CPT coding updated
    Effective DateSep 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateN/A
    Key ActionDocument the qualifying indication and confirm that ECMO will be performed at an ELSO case-registry-participating facility.
    SourceLink
    POLICY UPDATE CHANGES

    The June 2026 annual review updated references and CPT coding information.

    3Qualifying medical-necessity pathways
    ELSORequired facility case-registry participation
    4Primary CPT codes for ECMO initiation and daily management

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Potentially reversibleRequired characteristic of qualifying acute life-threatening dysfunction

    Medical Necessity Criteria

    Medically Necessary ECMO

    ECMO is considered medically necessary when ANY ONE of the following indications is met. The facility requirement applies to every covered pathway.

    ONE qualifying ECMO indication

    • Severe reversible acute dysfunction: The member has severe, life-threatening, but potentially reversible acute respiratory or cardiac dysfunction that is unresponsive to conventional management.
    • Pulmonary-failure bridge therapy: The member has pulmonary failure and is on a pulmonary transplant list.
    • Cardiac-failure bridge therapy: The member has cardiac failure and is eligible for a ventricular assist device or cardiac transplantation.

    Facility Requirement

    All covered ECMO procedures must meet this facility requirement.

    ELSO facility requirement: The procedure is performed at a facility participating in the Extracorporeal Life Support Organization (ELSO) case registry.

    CPT Coding

    CPT Codes: Initiation and Daily ManagementCPT
    33946Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-venous.
    33947ECMO/ECLS provided by physician, initiation, veno-arterial.
    33948ECMO/ECLS provided by physician, daily management, each day, veno-venous.
    33949ECMO/ECLS provided by physician, daily management, each day, veno-arterial.
    CPT Codes: Cannula Insertion and RepositioningCPT
    33951ECMO/ECLS provided by physician, insertion of peripheral cannula percutaneous, birth through 5 years of age.
    33952ECMO/ECLS provided by physician, insertion of peripheral cannula, percutaneous, 6 years and older.
    33953ECMO/ECLS provided by physician, insertion of peripheral cannula open, birth through 5 years of age.
    33954ECMO/ECLS provided by physician, insertion of peripheral cannula, open, 6 years and older.
    33955ECMO/ECLS provided by physician, insertion of central cannula by sternotomy or thoracotomy, birth through 5 years of age.
    33956ECMO/ECLS provided by physician, insertion of central cannula by sternotomy or thoracotomy, 6 years and older.
    33957ECMO/ECLS provided by physician, reposition of peripheral cannula, percutaneous, birth through 5 years of age.
    33958ECMO/ECLS provided by physician, reposition of peripheral cannula, percutaneous, 6 years and older.
    CPT Codes: Cannula and Left Heart Vent RemovalCPT
    33984ECMO/ECLS provided by physician, removal of peripheral cannula, open, 6 years of age and older.
    33989Removal of left heart vent by thoracic incision for ECMO/ECLS.

    Documentation and Coverage Risks

    Documentation Required

    Document the Qualifying Indication

    Document the qualifying indication supporting ECMO medical necessity. Coverage applies when the member has severe, life-threatening but potentially reversible acute respiratory or cardiac dysfunction that is unresponsive to conventional management, or when ECMO is used as an eligible bridge therapy.

    • Severe, life-threatening, potentially reversible acute respiratory or cardiac dysfunction unresponsive to conventional management.
    • Bridge therapy for pulmonary failure in a patient on a pulmonary transplant list.
    • Bridge therapy for cardiac failure in a patient eligible for a ventricular assist device or cardiac transplantation.
    Documentation Required

    Document ELSO Facility Participation

    Confirm and document that the ECMO procedure will be performed at a facility participating in the Extracorporeal Life Support Organization (ELSO) case registry.

    • Verify ELSO case-registry participation before the procedure.

    ECMO Overview

    Extracorporeal membrane oxygenation (ECMO) provides extracorporeal life support for patients with severe acute respiratory or cardiac dysfunction when conventional management is unsuccessful. Under this policy, ECMO may be medically necessary for severe, life-threatening, potentially reversible dysfunction or as bridge therapy to pulmonary transplantation, ventricular assist device placement, or cardiac transplantation.

    Key Terms

    ECMO/ECLS
    ECMOExtracorporeal membrane oxygenation provided by a physician.
    ECLSExtracorporeal life support; another term for extracorporeal membrane oxygenation.
    Veno-venous supportAn ECMO/ECLS support mode used for initiation or daily management.
    Veno-arterial supportAn ECMO/ECLS support mode used for initiation or daily management.
    Bridge therapy
    Bridge therapySupport for patients with pulmonary or cardiac failure while awaiting definitive treatment.
    Pulmonary-failure bridge
    Policy Summary
    PayerAmbetter Nevada
    PolicyExtracorporeal Membrane Oxygenation Therapy
    Policy CodePolicy WA.CP.MP.514
    Change TypeAnnual reviewreferences and CPT coding updated
    Effective DateSep 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateN/A
    Key ActionDocument the qualifying indication and confirm that ECMO will be performed at an ELSO case-registry-participating facility.
    SourceLink
    On This Page
    Medical Necessity CriteriaCPT CodingDocumentation and Coverage RisksECMO OverviewKey Terms
  1. Retain facility participation documentation in the medical record or authorization submission.
    2. Denial Risk

    No Qualifying Medical-Necessity Indication

    ECMO may not meet coverage criteria when the clinical circumstances do not satisfy a qualifying medical-necessity indication. In particular, coverage criteria are not met when the condition is not severe, life-threatening, potentially reversible, and unresponsive to conventional management, or when the applicable bridge indication is absent.

    • No qualifying acute respiratory or cardiac dysfunction.
    • No documented failure of conventional management.
    • No eligible pulmonary-transplant or cardiac-failure bridge indication.
    Denial Risk

    Non-ELSO Facility Creates Coverage Risk

    Procedures performed at a facility that does not participate in the ELSO case registry may be at risk for coverage denial because facility participation is a stated coverage requirement.

    • Confirm ELSO participation before scheduling ECMO.
    • Document the facility's ELSO case-registry participation with the authorization request.
    For patients in pulmonary failure who are on a pulmonary transplant list.
    Cardiac-failure bridgeFor patients in cardiac failure who are eligible for a ventricular assist device or cardiac transplantation.