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Coverage criteria policies

Airway clearance system / chest compression generator system

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative Process

  • Prior authorization is required for an airway clearance/ high frequency chest wall compression (HFCWC) system (E0483). A HFCW system consists of the vest, generator, and hoses.
  • Prior authorization is required for a replacement HFCWC system (E0483).
  • Prior authorization is not required for a replacement vest (A7025) or hoses (A7026).

Coverage

Airway clearance systems (also known as chest compression generators, high-frequency chest wall compression systems, high frequency chest wall oscillation devices, bronchial drainage vests, or air pulse generator systems) are generally covered subject to the indications listed below and per your plan documents. If the system is covered, it is in lieu of health plan payment for chest physiotherapy provided by a professional or other mechanical device.

Indications that are covered

An airway clearance system/high-frequency chest wall compression system is eligible for coverage when the following criteria are met:

  1. The member has one of the following diagnoses:
    1. Cystic Fibrosis or immotile cilia syndrome
    2. Chronic Bronchiectasis which has been confirmed by radiological scan and is characterized by:
      1. Daily productive cough for at least 6 continuous months; or
      2. More than two exacerbations in a 12 month period which required antibiotic treatment
  2. Documentation indicates that the member has received optimal medical management (e.g. antibiotics, bronchodilators and other techniques to enhance mucous clearance such as use of a flutter valve and/or chest physiotherapy).
  3. Documentation indicates that the standard treatments noted above have either failed to help the member mobilize secretions or cannot be performed.
  4. When these criteria are met, the airway clearance system/ high-frequency chest wall compression system will be covered for an initial rental period not to exceed three months. Coverage beyond three months requires a new prior authorization request which indicates that the member is consistently using the device.
  5. A replacement HFCWC system (E0483) may be covered as an outright purchase/ rent to own when
    1. it is non-functional due to normal wear and tear, and
    2. it is no longer covered under the manufacturer’s warranty, and
    3. it has been determined by the durable medical equipment (DME) vendor to require repairs which are not cost effective.

Indications that are not covered

  1. High frequency chest wall compression is considered investigative for all other indications, including but not limited to neuromuscular disorders.
  2. The chest compression generator system would not be considered as therapy of choice for members with one or more of the following conditions:
    1. Head, neck or chest injury
    2. Spinal instability
    3. History of pneumothorax (collapsed lung) or hemoptysis (the coughing up of blood)
    4. A known cardiac condition including cardiac arrest within the past 30 days

Definitions

An airway clearance system/chest compression generator system/high frequency chest wall compression system assists the member with chest drainage. Treatments are administered daily for up to one hour via a specially fitted inflatable vest which is worn by the member and attached to a chest compression system hose and generator. The machine vibrates the chest at a high frequency to loosen and thin mucous in the lungs. Oscillation periods of 5 to 10 minutes are alternated with pauses for coughing, huffing or suctioning to help the member clear secretions. Examples of brand names include SmartVest, InCourage, and the VEST.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

E0483

High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each

A7025

High frequency chest wall oscillation system vest, replacement for use with patient owned equipment, each

A7026

High frequency chest wall oscillation system hose, replacement for use with patient owned equipment, each

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

Items must be received from a contracted vendor for in-network benefits to apply.

References

  1. American Association for Respiratory Care (AARC) Clinical Practice Guideline: Postural drainage therapy. (1991). Respiratory Care, 36(12), 1418–1426.
  2. Clinkscale, D., Spihlman, K. Watts, P. Rosenbluth, D. & Kollef, M. (2012.) A randomized trial of conventional chest physical therapy versus high frequency chest wall compressions in intubated and non-intubated adults. Respiratory Care, 57(2), 22-228.
  3. ECRI Institute. (2013.) Hotline Response: High Frequency Chest Compression for Airway Clearance. Plymouth Meeting, PA: ECRI Institute.
  4. Emmons, E. Bronchiectasis Treatment and Management. Updated June, 2018. Retrieved 7/6/18 from https://emedicine.medscape.com/article/296961-treatment
  5. Fakhoury, K. Management of bronchiectasis in children without cystic fibrosis. In: UpToDate, Mallory, G. B. (Ed), UpToDate, Waltham, MA. (Accessed on June 29, 2018.)
  6. Hayes, Inc. Hayes Impact Comparison Worksheet. High-Frequency Chest Wall Compression for Diseases Other than Cystic Fibrosis. Lansdale, PA: Hayes, Inc.; July, 2014.
  7. Hayes, Inc. Hayes Medical Technology Directory Report. High-Frequency Chest Wall Compression for Cystic Fibrosis. Lansdale, PA: Hayes Inc.; December, 2016. Reviewed December, 2017.
  8. Hayes, Inc. Hayes Medical Technology Directory Report. High-Frequency Chest Wall Compression for Diseases Other than Cystic Fibrosis. Lansdale, PA: Hayes, Inc.; August, 2016. Reviewed March, 2018.
  9. McCool, D. & Rosen, M. (2006). Nonpharmacologic airway clearance therapies: AACP evidence based clinical practice guidelines. Chest - Official Publication of the American College of Chest Physicians. 129(1 Suppl), 250S-259S.
  10. McShane, P., Naureckas, E. T., Tino, G. & Strek, M. E. (2013). Non-cystic fibrosis bronchiectasis. American Journal of Respiratory and Critical Care Medicine, 188(6), 1-35.
  11. Miller, R. G., Jackson, C. E., Kasarskis, E. J., England, J. D., Forshew, D., Johnston, W., … Woolley, S. C. (2009). Practice Parameter update: The care of the patient with amyotrohic lateral sclerosis: Drug, nutritional, and respiratory therapies (an evidence-based review). Neurology, 73(15), 1218-1226.
  12. Simon, R. H. Cystic fibrosis: Overview of the treatment of lung disease. In: UpToDate, Mallory, G. (Ed), UpToDate, Waltham, MA. (Accessed on June 29, 2018).
  13. Strickland, S. L., Rubin, B. K., Drescher, G. S., Haas, C. F., O’Malley, C. A., Volsko, T. A., … Hess, D. R. (2013). AARC Clinical Practice Guideline: Effectiveness of nonpharmacologic airway clearance therapies in hospitalized patients. Respiratory Care, 58(12), 2187-2193.

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Policy activity

  • 04/30/1994 - Date of origin
  • 11/01/2018 - Effective date
Review date
  • 06/2018
Revision date
  • 07/31/2018

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