Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut MED.00098 Hyperoxemic Reperfusion Therapy Form

Effective Date

06/28/2023

Last Reviewed

05/11/2023

Original Document

  Reference



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

  • Intracoronary hyperoxemic perfusion (IHP)
  • Supersaturated oxygen infusion therapy
  • Superoxygenation therapy
  • Aqueous oxygen (AO) therapy
  • SSO2

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.