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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).
  • The HFCWO system may be initially authorized for a 3 month rental period subject to the coverage criteria listed below and per your plan documents. 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 OR
      2. More than 2 exacerbations in 12 months requiring antibiotic treatment.
    3. Chronic neuromuscular disease with a history of pneumonia
  2. 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.

Definitions

A High Frequency Chest Wall Oscillation (HFCWO) 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.

The services associated with these codes require prior authorization:

Codes

Description

E0483

High frequency chest wall oscillation air-pulse generator system

The services associated with these codes do not require prior authorization:

Codes

Description

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

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. Portions of this policy were taken from the MHCP provider manual website: http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=DHS16_152808

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Policy activity

  • 06/12/2017 - Date of origin
  • 06/12/2017 - Effective date

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