Total Body and Regional Hypothermia
DESCRIPTION
Total body and regional hypothermia is the lowering of the total body temperature to less than 30 degrees Celsius in order to limit ischemic damage during surgical procedures. Total body hypothermia is an integral part of certain procedures, such as open-heart surgery. Regional body hypothermia, involving catheter infusion of iced saline solution, is used during procedures that involve clamping a critical artery; common examples include renal procedures.
POLICY
Total body and regional hypothermia as a technique to limit ischemic damage is considered medically necessary.
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
SOURCES
Axelrod, Y. K., & Diringer, M. N. (2008). Temperature management in acute neurologic disorders. Neurologic Clinics, 26 (2), 585-603.
BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2003). Total body and regional hypothermia (2.01.11). Retrieved August 12, 2011 from BlueWeb. (0 articles and/or guidelines reviewed)
Dine, C. J., & Abella, B. S. (2009). Therapeutic hypothermia for neuroprotection. Emergency Medicine Clinics of North America, 27 (1), 137-149.
ECRI Institute. Health Technology Information Service. Emerging Technology (TARGET) Evidence Report. (2010, May). Therapeutic hypothermia for acute ischemic stroke. Retrieved August 12, 2011 from ECRI Institute. (25 articles and/or guidelines reviewed)
ECRI Institute. Health Technology Information Service. Emerging Technology (TARGET) Evidence Report. (2009, January). Therapeutic hypothermia after cardiac arrest. Retrieved August 12, 2011 from ECRI Institute. (25 articles and/or guidelines reviewed)
Nguyen, H. P., Zaroff, J. G., Bayman, E. O., Gelb, A. W., Todd, M. M., Hindman, B. J., et al. (2010). Perioperative hypothermia (33 degrees C) does not increase the occurrence of cardiovascular events in patients undergoing cerebral aneurysm surgery: Findings from the Intraoperative Hypothermia for Aneurysm Surgery trial. Anesthesiology, 113 (2), 327-342.
U. S. Food and Drug Administration. (2010, October). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K101987. Retrieved August 15, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf10/K101987.pdf.
U. S. Food and Drug Administration. (2007, August). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K072234. Retrieved August 15, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf7/K072234.pdf.
ORIGINAL EFFECTIVE DATE: 4/1981
MOST RECENT REVIEW DATE: 9/22/2011
ID_BA
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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