Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Several forms of mechanical devices are used to help clear secretions in persons who have severe lung disease such as cystic fibrosis.

2)    These devices require pre-authorization.

3)    When approved, they are covered under the DME benefit.

4)    Intrapulmonary percussive ventilators (IPV) are considered experimental and investigational as there is insufficient evidence supporting their effectiveness.

1)    The following airway clearance devices are considered medically necessary durable medical equipment (DME) to assist in mobilizing respiratory tract secretions for members with the following conditions: 

a)    Airway oscillating devices (e.g., Flutter and Acapella) are considered medically necessary for cystic fibrosis (E84.0), bronchitis (J41.0 – J42), bronchiectasis (Q33.4, J47.0 – J47.9), and asthma (J44.0 – J45.998).

b)    Mechanical percussors (e.g., Fluid Flo and Frequencer) are considered medically necessary for cystic fibrosis (E84.0), chronic bronchitis (J41.0 – J42), bronchiectasis (Q33.4, J47.0 – J47.9), immotile cilia syndrome (J39.8), and asthma (J44.0 – J45.998).

c)    Positive expiratory pressure (PEP) mask is considered medically necessary for cystic fibrosis (E84.0), chronic bronchitis (J41.0 – J42), asthma (J44.0 – J45.998), and chronic obstructive pulmonary disease (J44.9).

2)    High-frequency chest compression systems (the SmartVest, the MedPulse Respiratory Vest System, the Vest Airway Clearance System, the ABI Vest, and the InCourage Vest/System) are considered medically necessary in lieu of chest physiotherapy for the following indications, where there is a documented failure of standard treatments to adequately mobilize retained secretions, including chest physiotherapy:

a)    Bronchiectasis (Q33.4, J47.0-J47.9), confirmed by CT scan, characterized by daily productive cough for at least 6 continuous months or by frequent (i.e., more than 2 times per year) exacerbations requiring antibiotic therapy; or

b)    Cystic fibrosis (E84.0); or

c)    The member has one of the following neuromuscular disease diagnoses:

1.    Acid maltase deficiency (E74.00)

2.    Anterior horn cell diseases (G12.0 – G12.9)

3.    Hereditary muscular dystrophy (G71.0)

4.    Multiple sclerosis (G35)

5.    Myotonic disorders (G71.11-G71.19)

6.    Other myopathies (G71.3 – G71.9, G72.81 – G72.9)

7.    Paralysis of the diaphragm (J98.6)

8.    Post-polio (G14)

9.    Quadriplegia (G82.50 – G82.54)

d)    Lung transplant recipients, within the first 6 months post-operatively, who are unable to tolerate standard chest physiotherapy.

e)    High-frequency chest compression systems are considered experimental and investigational for other indications (e.g., alpha 1-antitrypsin deficiency, coma, kyphosis, leukodystrophy, and scoliosis).

3)    Mechanical in-exsufflation devices are considered medically necessary DME for persons with a neuromuscular disease (e.g., amyotrophic lateral sclerosis, high spinal cord injury with quadriplegia) that is causing a significant impairment of chest wall and/or diaphragmatic movement and for whom standard treatments (e.g., chest percussion and postural drainage, etc.) have not been successful in adequately mobilizing retained secretions.

Codes Used In This BI:

Intrapulmonary percussive ventilators (IPV) are considered experimental and investigational as there is insufficient evidence supporting their effectiveness.

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