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Coverage criteria policies

Airway clearance system/ high frequency chest wall compression system – Minnesota Health Care Programs

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 documents will be used to determine your coverage.

Administrative Process

  • Prior authorization is not required for cough assist devices (E0480, E0482, E0484)
  • Prior authorization is required for High Frequency Chest Wall Oscillation (HFCWO) systems (E0483).
  • When the criteria below are met, the HFCWO system will be initially authorized for a 3 month rental period. Continued rental or purchase after the initial 3 month period requires separate prior authorization with clinical documentation of ongoing medical necessity.


Airway clearance devices are generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

  1. High Frequency Chest Wall Oscillation (HFCWO) air-pulse generator systems are covered for members when standard chest physiotherapy has failed or is medically contraindicated and the member has one of the following indications:
    1. Cystic fibrosis
    2. Chronic bronchiectasis, confirmed by radiological scan, and
      1. Daily productive cough for at least six continuous months
      2. More than two exacerbations in 12 months requiring antibiotic treatment.
    3. One of the following neuromuscular disease diagnoses:
      1. Acid maltase deficiency
      2. Anterior horn cell diseases
      3. Hereditary muscular dystrophy
      4. Multiple sclerosis
      5. Myotonic disorders
      6. Other myopathies
      7. Paralysis of the diaphragm
      8. Post polio
      9. Quadriplegia
  2. HFCWO replacement vests are covered for use with member-owned systems when the original vest is lost, stolen or damaged beyond repair and not covered by a warranty.
    1. Documentation must state the reason the vest needs replacement, and when the warranty period ended.
  3. Documentation for HFCWO systems must include chart documentation that addresses the following. A checklist is not sufficient to establish medical need:
    1. Diagnosis
    2. History of respiratory infections
    3. History of chest physiotherapy and the reason it is not meeting the member’s needs or is medically contraindicated.

Indications that are not covered

  1. HFCWO systems are not covered for members who have known cardiac conditions.
  2. Intrapulmonary percussive ventilation devices are not covered for any indication because they are not standard in community care and substantive research is lacking.

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.




High frequency chest wall oscillation air-pulse generator system


Percussor, electric or pneumatic, home model


Cough stimulating device, alternating positive and negative airway pressure


Oscillatory positive expiratory pressure device, nonelectric, any type, each


High frequency chest wall oscillation system vest, replacement

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


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.


Item must be received from a contracted vendor or provider.


  1. Minnesota Health Care Programs (MHCP) Provider Manual. Equipment and Supplies: Airway Clearance Devices. Revised 05-13-2019.

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Policy activity

  • 06/12/2017 - Date of origin
  • 05/13/2019 - Effective date
Review date
  • 06/2019
Revision date
  • 05/29/2019

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