Medical Policy

Effective Date:10/01/2010 Title:Airway Clearance Devices
Revision Date:01/01/2019 Document:BI268:00
CPT Code(s):A7025, A7026,E0480, E0484, E0482, E0483, S8185, E0481
Public Statement

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.

Medical Statement

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:


High freq chest wall oscillation syst vest, rplcmt for use w/ pt-owned equipmt, ea


High freq chest wall oscillation syst hose, rplcmt for use w/ pt-owned equipmt, ea


Percussor, electric or pneumatic, home model


Intrapulmonary percussive ventilation syst & related accessories


Cough stimulating device, alternating positive & negative airway pressure


High freq chest wall oscillation syst, (incl all access & suppl), ea (code revised 1/1/19)


Oscillatory positive expiratory pressure dvc, nonelec, any type, ea


Flutter device


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

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Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.