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A. ECMO is covered (subject to Limitations/Exclusions and Administrative Guidelines) for critically ill newborns (age 28 days or younger) with respiratory failure after conservative management (medication and mechanical ventilation) is found to be ineffective and all of the following clinical criteria are met: 1. The newborn's corrected gestational age is 34 weeks or more, and surgical cannulation is possible (corresponding to a birth weight of about 2,000 grams); 2. The newborn has reversible lung disease; and 3. The newborn has not been on mechanical ventilation for more than 14 days. B. ECMO is covered (subject to Limitations and Administrative Guidelines) for adults and children with acute severe cardiac or pulmonary failure that is potentially reversible after conservative management (medication and mechanical ventilation) is found to be ineffective. Clinical situations that may prompt the initiation of ECMO include the following: 1. Hypoxemic respiratory failure with a ratio of arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2) of <100 mmHg despite optimization of the ventilator settings, including the tidal volume, positive end-expiratory pressure (PEEP), and inspiratory to expiratory (I:E) ratio; 2. For adults with Acute Respiratory Distress Syndrome (ARDS) in severe respiratory failure (PaO2/FiO2 <70); 3. Hypercapnic respiratory failure with an arterial pH less than 7.20; 4. Cardiac/circulatory failure/refractory cardiogenic shock; 5. Massive Pulmonary Embolism; 6. Failure to wean from cardiopulmonary bypass after cardiac surgery; or 7. As a bridge to either cardiac transplantation or placement of a ventricular assist device (VAD). C. The underlying disease is not the only consideration when evaluating the need for ECMO but also an assessment of: 1. Gas exchange in relation to current levels of mechanical ventilation; 2. The rate of deterioration; and 3. The success of other rescue therapies. D. Specific cut-offs at which ECMO should be offered or withheld have not been firmly established and therefore should be evaluated on a case-by-case basis. I. Policy

Extracorporeal membrane oxygenation for severe respiratory failure