Medical Policy



Subject: Hyperoxemic Reperfusion Therapy
Document #: MED.00098 Current Effective Date:    09/27/2017
Status: Reviewed Last Review Date:    08/03/2017

Description/Scope

This document addresses the use of hyperoxemic reperfusion (HR) therapy.  This treatment is known by other names including:  

HR therapy is a treatment in which arterial blood is removed, supersaturated with oxygen, and then reinfused into the person's blood stream at the site of cardiac injury.  The intent of this treatment is to decrease myocardial damage following percutaneous placement of an intravascular coronary artery stent for the treatment of myocardial infarction (MI).

Position Statement

Investigational and Not Medically Necessary:

Use of hyperoxemic reperfusion therapy is considered investigational and not medically necessary for all indications.

Rationale

A non-randomized controlled trial by Trabattoni and colleagues published in 2006 compared 27 individuals with acute MI who received HR therapy, and a control group of 24 MI subjects who received standard therapy.  The authors reported participants in the HR group showed a significantly shorter time-to-peak creatine kinase release (4.8 ± 2.2 hour [hr], p=0.001), a shorter creatine kinase half-life period (23.4 ± 8.9 hr vs. 30.5 ± 5.8 hr, p=0.006), and a higher rate of complete ST-segment resolution (78% vs. 42%, p=0.01).  Additionally, the HR group also demonstrated a significant improvement of mean left ventricular ejection fraction (LVEF; from 44 ± 9% to 55 ± 11%, p<0.001) and wall motion score index (from 1.77 ± 0.2 to 1.39 ± 0.4, p<0.001) at 3 months post-treatment.  The small size and non-randomized design of this study weaken the positive findings.

The Acute Myocardial Infarction with Hyperoxemic Therapy (AMIHOT) I study involved 269 subjects assigned to receive either HR or normoxemic (e.g., normal) blood autoreperfusion (O'Neill, 2007).  There was no significant difference in the incidence of the primary endpoints between the study groups.  However, in the post-hoc analysis, individuals with anterior acute MI who were treated for longer than 6 hours with HR therapy had a greater improvement in regional wall motion, smaller infarct, and improved ST-segment resolution compared with normoxemic controls.

The largest available study was a randomized controlled trial (RCT) conducted by Stone and colleagues (2009).  AMIHOT II study involved 301 subjects with anterior ST-segment myocardial infarction (MI) randomized to receive either standard treatment (n=79) or 90 minutes of HR with intracoronary supersaturated oxygen delivery combined with standard treatment (n=222).  The authors reported that among the 281 randomized subjects who received SPECT imaging, infarct size was 26.5% in the control group compared with 20.0% in the HR group (unadjusted p=0.10; adjusted p=0.03).  Post-hoc analysis indicated that infarct size was correlated with LVEF.  In participants with LVEF less than 40%, infarct size was reduced from 33.5% in the control group to 23.5% in the HR group.  Such differences were not noted in the group of subjects with LVEF greater than 40%.  No significant differences between groups were noted in terms of cardiac biomarkers or ST-segment measurement.  At 30 days, the incidence of major cardiac adverse events was not significantly different between treatment and control groups.

There are a limited number of peer-reviewed published clinical studies evaluating the safety and efficacy of HR therapy for the treatment of individuals with MI.  Two RCTs of moderate size, one small non-randomized controlled trial, and one small case series were identified during the search of the peer-reviewed literature.  Overall study results indicated that hyperoxemic therapy resulted in no significant differences in primary outcome measures when compared with controls.  Additional well-designed studies with appropriate comparators are necessary to establish the safety and efficacy of HR therapy in individuals with MI.

Background/Overview

HR therapy, also known intracoronary hyperoxemic perfusion (IHP), supersaturated oxygen infusion therapy, superoxygenation therapy, aqueous oxygen (AO) therapy, and SSO2, is designed to lessen the damage to cardiac tissue due to an acute MI.  This procedure involves the use of a device that removes arterial blood from a person, supersaturates it with oxygen to create highly oxygen-enriched blood and then reintroduces the supersaturated blood into the person's affected coronary artery following percutaneous intervention with coronary artery stent placement.

At this time there is currently no United States Food and Drug Administration (FDA) approved device to deliver hyperoxemic reperfusion therapy.  One device, the TherOx Downstream® AO System manufactured by TherOx Inc. of Irvine, CA, is undergoing investigation in preparation for the FDA review process, study completion is anticipated in 2018 (NCT 02603835, clinicaltrials.gov).

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.  

When Services are Investigational and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

CPT  
96379 Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusion [when specified as hyperoxemic reperfusion therapy]
   
ICD-10 Procedure  
5A0512C Extracorporeal supersaturated oxygenation, intermittent
5A0522C Extracorporeal supersaturated oxygenation, continuous
   
ICD-10 Diagnosis  
  All diagnoses
   
References

Peer Reviewed Publications: 

  1. Dixon SR, Bartorelli AL, Marcovitz PA, et al. Initial experience with hyperoxemic reperfusion after primary angioplasty for acute myocardial infarction: results of a pilot study utilizing intracoronary aqueous oxygen therapy. J Am Coll Cardiol. 2002; 39(3):387-392.
  2. O'Neill WW, Martin JL, Dixon SR, et al: AMIHOT Investigators. Acute Myocardial Infarction with Hyperoxemic Therapy (AMIHOT): a prospective, randomized trial of intracoronary hyperoxemic reperfusion after percutaneous coronary intervention. J Am Coll Cardiol. 2007; 50(5):397-405.
  3. Stone GW, Martin JL, de Boer MJ, et al. Effect of supersaturated oxygen delivery on infarct size after percutaneous coronary intervention in acute myocardial infarction. Circ Cardiovasc Interv. 2009; 2(5):366-375.
  4. Trabattoni D, Bartorelli AL, Fabbiocchi F, et al. Hyperoxemic perfusion of the left anterior descending coronary artery after primary angioplasty in anterior ST-elevation myocardial infarction. Catheter Cardiovasc Interv. 2006; 67(6):859-865.
  5. Warda HM, Bax JJ, Bosch JG, et al. Effect of intracoronary aqueous oxygen on left ventricular remodeling after anterior wall st-elevation acute myocardial infarction. Am J Cardiol 2005; 96(1):22-24.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. TherOx. Evaluation of intracoronary hyperoxemic oxygen therapy in anterior acute myocardial infarction patients (IC-HOT). NLM Identifier: NCT02603835. Last updated on February 05, 2016. Available at: https://clinicaltrials.gov/ct2/show/NCT02603835?term=sso2&rank=1 . Accessed on June 19, 2017.
Document History
Status Date Action
Reviewed 08/03/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Background/Overview and References sections.
Reviewed 08/04/2016 MPTAC review. Updated Reference section. Removed ICD-9 codes from Coding section.
Reviewed 08/06/2015 MPTAC review. Updated Rationale, Background/Overview and Reference sections.
Reviewed 08/14/2014 MPTAC review. Updated Description/Scope, Rationale and Reference sections.
Reviewed 08/08/2013 MPTAC review.
Reviewed 08/09/2012 MPTAC review. Revised Rationale and Reference sections.
Reviewed 08/18/2011 MPTAC review.
Reviewed 08/19/2010 MPTAC review. Updated Rationale and Reference sections.
Reviewed 08/27/2009 MPTAC review.
New 08/28/2008 MPTAC review. Initial document development.