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AetnaAll Plans · Coverage · Medical Policy · Cardiology, Critical Care, Emergency Medicine +2 moreMedium impact

Intra-coronary Hyperoxemic Therapy (CPB 0801, reviewed 2026-10-28)

Effective date
Not stated in the notice
Identified
Oct 29, 2026

Summary

Aetna's Clinical Policy Bulletin 0801 states that intra-coronary hyperoxemic therapy, also called aqueous oxygen therapy, is experimental, investigational or unproven for carbon monoxide poisoning, cardiogenic shock, radio-contrast nephropathy, reperfusion microvascular ischemia in persons with acute myocardial infarction, and stroke, because the evidence is insufficient. The policy lists ICD-10 codes as not covered for the indications listed in the policy, and says there are no specific CPT or HCPCS codes for hyperoxemic therapy.

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What to do

Action · 1 steps
01Billing team: Claims for intra-coronary hyperoxemic therapy for carbon monoxide poisoning, cardiogenic shock, radio-contrast nephropathy, reperfusion microvascular ischemia in persons with acute myocardial infarction, or stroke are not covered under this policy, because Aetna considers the therapy experimental, investigational or unproven for these indications and the listed ICD-10 codes are not covered for them.

Codes mentioned

G45.0G45.2G45.4G45.9I21.01I22.9I60.00I67.2I67.4I69.998I97.810I97.821N04.0N05.9N07.0N07.9R57.0T50.8X5T58.01XT58.94XT59.891X00.1XXX02.1XX

Original notice

Intra-coronary Hyperoxemic Therapy (CPB 0801, reviewed 2026-10-28)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesCardiologyCritical CareEmergency MedicineNephrologyNeurologyCode G45.0Code G45.2Code G45.4Code G45.9Code I21.01Code I22.9Code I60.00Code I67.2Code I67.4Code I69.998Code I97.810Code I97.821Code N04.0Code N05.9Code N07.0Code N07.9Code R57.0Code T50.8X5Code T58.01XCode T58.94XCode T59.891Code X00.1XXCode X02.1XX

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