Medical Policy: 01.01.01
Original Effective Date: February 1995
Reviewed: June 2015
Revised: June 2015
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Cystic fibrosis, chronic bronchitis, bronchiectasis, immotile cilia syndrome, neuromuscular disease with progressive respiratory muscle weakness, asthma and some acute respiratory tract infections are some of the conditions that can lead to abnormal airway clearance or increase sputum production.
Chest physiotherapy is a treatment that attempts to compensate for abnormal airway clearance by removing mucopurulent secretions. However, the standard of care remains manual clapping, vibration and compression, together with postural drainage and assisted coughing.
A conventional manual chest percussion and postural drainage program to remove accumulated secretions requires a caregiver's assistance and may cause children and adults to be less compliant with a treatment regimen. Many alternative oscillatory devices are designed to provide self-administered airway clearance and have been investigated as an alternative to percussion and postural drainage.
High frequency oscillatory chest compression devices (e.g., the Frequencer, the SmartVest, the MedPulse Respiratory Vest System, the Vest Airway Clearance System, the ABI Vest, Respin11 Bronchial Clearance System, and the InCourage Vest/System) are passive oscillatory devices designed to provide airway clearance without the active participation of the patient. The Vest Airway Clearance System provides high-frequency chest compression using an inflatable vest and an air-pulse generator. Large-bore tubing connects the vest to the air-pulse generator. The air-pulse generator creates pressure pulses that cause the vest to inflate and deflate against the thorax, creating high-frequency chest wall oscillation and mobilization of pulmonary secretions.
Mechanical percussor (e.g., Fluid Flo and Frequencer, including acoustical percussor Vibralung) The purpose of percussion is to apply kinetic energy to the chest wall and lung at regular intervals. Percussion is also referred to as cupping, clapping, and tapotement. It can be accomplished by rhythmically striking the thorax with a cupped hand or a mechanical device applied directly over the lung segment(s) being drained. According to the guidelines developed by American Association for Respiratory Care (AARC) on postural drainage therapy, no convincing evidence demonstrates the superiority of one method over the other.
Vibratory/oscillatory positive expiratory pressure (PEP) devices (FLUTTER®, Acapella®) With PEP devices. in which the patient exhales multiple times through a device. The FLUTTER device is a small pipe-shaped, easily portable hand-held device, with a mouthpiece at one end. It contains a high-density stainless steel ball that rests in a plastic circular cone. During exhalation, the steel ball moves up and down, creating oscillations in expiratory pressure and airflow. When the oscillation frequency approximates the resonance frequency of the pulmonary system, vibration of the airways occurs, resulting in loosening of mucus. The Acapella device is similar in concept but uses a counterweighted plug and magnet to create air flow oscillation.
Intrapulmonary percussive ventilator (e.g., the Percussionaire and the TXP® Universal VENTILATOR Percussionator®) This device combines internal thoracic percussion through rapid minibursts of inhaled air and continuous therapeutic aerosol delivered through a nebulizer. An aerosol machine that delivers a series of pressurized gas minibursts at rates of 100 to 225 cycles/min to the respiratory tract. Aerosolized medications can be delivered under pressure and with oscillations that vibrate the chest.
Mechanical insufflation – exsufflation device (CoughAssist, known as In-Exsufflator, Cofflator, cough machine) is designed to inflate the lung with positive pressure and assist cough with negative pressure. Report by the American College of Chest Physicians stated that "[t]he inability of patients with respiratory muscle weakness to achieve high lung volumes is likely to contribute to cough ineffectiveness. Increasing the inhaled volume prior to cough by air-stacking positive pressure breaths or by glossopharyngeal breathing increases cough expiratory flows by 80 % in these patients. Cough efficiency may be further enhanced by the application of negative pressure to the airway for a period of 1 to 3 s. Using this technique of mechanical insufflation-exsufflation, peak cough expiratory flows can be increased by more than four-fold."
One of the following devices may be considered medically necessary for the one of the following scenarios:
High frequency oscillatory chest wall compression devices for airway clearance in patients with:
- Cystic Fibrosis
- Chronic Diffuse Bronchiectasis (Chronic diffuse brochiectasis is defined by: daily productive cough for at least 6 continuous months, or more than 2 times a year exacerbations requiring antibiotic therapy, and confirmed by high resolution or spiral chest computed tomography scan.)
- Duchenne Muscular Dystrophy, Amyotrophic Lateral Sclerosis (ALS) or Spinal Muscular Atrophy (SMA)-as part of the bronchial hygiene protocol when the member is ventilatory dependant and doesn’t tolerate manual chest physiotherapy.
High-frequency chest wall compression devices are considered not medically necessary as an alternative to chest physical therapy in patients with cystic fibrosis, neurodegenerative diseases, or chronic bronchiectasis in any other clinical situation. There is a lack of clinical data to show that these devices provide any additional health benefit compared to conventional chest physical therapy in these situations.
There is insufficient evidence for the use of high frequency chest wall compression therapy in those with other conditions. The evidence is limited and insufficient to support definitive conclusions. There has not been adequate evidence to prove superiority over manual therapy. Therefore, use of high frequency chest wall compression in other conditions is considered not medically necessary.
Mechanical percussors for airway clearance in patients with:
- for cystic fibrosis
- chronic bronchitis
- chronic bronchiectasis
The use of Vibralung the auditory percussor, which is considered an upgrade, is only medically necessary for cystic fibrosis, chronic bronchitis, chronic bronchiectasis) in the clinical scenario where a mechanical percussor can not be used (i.e burns, chest trauma).
Vibratory/oscillatory positive expiratory pressure device for airway clearance in patients with:
- cystic fibrosis
- chronic bronchitis
Positive expiratory pressure (PEP) mask for airway clearance in patients with:
- cystic fibrosis
- chronic bronchitis
Mechanical insufflation-exsufflation devices for airway clearance in patients with:
- Progressive neurodegenerative/neuromuscular disease, including Duchenne’s Muscular Dystrophy, Spinal Muscular Atrophy and Amyotrophic Lateral Sclerosis or spinal cord injury and impaired ability to cough, who require ventilatory assistance.
The use of intrapulmonary percussion ventilation in the home setting has not been proven safe or more effective than manual CPT. The safety of home use has been questioned in the home setting. The use of IPV ventilation in the home setting is considered investigational.
Other applications of airway clearance devices, including, but not limited to their use with other lung diseases and other neuromuscular disorders is considered investigational.
The upgrading of a covered device to a newer model due to preference or convenience is considered not medically necessary.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 94669 Mechanical chest wall oscillation to facilitate lung function, per session
- E0480 Percussor device, electric or pneumatic, home model
- E0481 Intrapulmonary percussive ventilation system and related accessories
- E0482 Cough stimulating device, alternating positive and negative airway pressure (mechanical insufflation-exsufflation)
- E0483 High frequency chest wall oscillation air-pulse generator system (includes hoses and vest), each
- E0484 Oscillatory positive pressure device, non-electric, any type, each
Date Reason Action
October 2010 Annual review Policy renewed
November 2011 Annual review Policy revised
October 2012 Annual review Policy renewed
September 2013 Annual review Policy revised
July 2014 Annual review Policy revised
June 2015 Annual review Policy revised
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.