MED.00098 Hyperoxemic Reperfusion Therapy

This policy addresses hyperoxemic reperfusion therapy (also called intracoronary hyperoxemic perfusion, supersaturated oxygen [SSO2] therapy, or aqueous oxygen therapy), including devices such as the TherOx Downstream System used after PCI for acute myocardial infarction. Anthem considers HR/SSO2 therapy investigational and not medically necessary; it is not covered for any indication. This applies regardless of FDA approval, clinical scenario (e.g., LAD treatment within 6 hours post-PCI), or billing code (e.g., 96379).

"Use of hyperoxemic reperfusion therapy is consideredinvestigational and not medically necessaryfor all indications."

Sign up to see full coverage criteria, indications, and limitations.