Skip to main content
HealthPartners

Coverage criteria policies

Airway clearance system/chest compression generator 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.

Coverage

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 6 continuous months
      2. More than 2 exacerbations in 12 months requiring antibiotic treatment.
    3. Chronic neuromuscular disease with a history of pneumonia
  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 clinic notes that address 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 investigative.

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

E0480

Percussor, electric or pneumatic, home model

E0482

Cough stimulating device, alternating positive and negative airway pressure

E0484

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

A7025

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.

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

Item must be received from a contracted vendor or provider.

References

  1. Minnesota Health Care Programs (MHCP) Provider Manual. Equipment and Supplies: Airway Clearance Devices. Revised 09-22-2017.

Go to

Policy activity

  • 06/12/2017 - Date of origin
  • 08/01/2018 - Effective date
Review date
  • 06/2018
Revision date
  • 07/27/2018

Related content