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Medical Policy: 01.01.01
Original Effective Date: February 1995
Reviewed: November 2011
Revised: November 2011
Benefit Application
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.
Description:
Cystic fibrosis, chronic bronchitis, bronchiectasis, immotile cilia syndrome, asthma and some acute respiratory tract infections are some of the conditions that can lead to abnormal airway clearance or increase sputum production. 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.
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
- Mechanical percussors
- Vibratory/oscillatory positive expiratory pressure devices (FLUTTER®, Acapella® )
- Positive expiratory pressure devices
- Intrapulmonary percussive ventilator
- Mechanical insufflation – exsufflation device
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Prior Approval:
Not applicable
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Policy:
One of the following devices may be considered medically necessary for the conditions listed below:
- High frequency oscillatory chest wall compression devices or intrapulmonary percussive ventilation devices for airway clearance in patients with cystic fibrosis or chronic diffuse bronchiectasis when standard chest physiotherapy has failed, OR if appropriate, FLUTTER® device failure, OR standard chest physiotherapy is unavailable or not tolerated
- Mechanical percussors for cystic fibrosis, chronic bronchitis and bronchiectasis.
- Vibratory/oscillatory positive expiratory pressure device for cystic fibrosis, chronic bronchitis and bronchiectasis.
- Positive expiratory pressure device for cystic fibrosis and chronic bronchitis.
- Mechanical insufflation-exsufflation devices may be covered for patients with neuromuscular disease or spinal cord injury and impaired ability to cough, who require ventilatory assistance.
High-frequency chest wall compression devices are considered not medically necessary as an alternative to chest physical therapy in patients with cystic fibrosis or chronic bronchiectasis in any other clinical situations; there are no clinical data to show that these devices provide any additional health benefit compared to conventional chest physical therapy in these situations.
Other applications of airway clearance devices, including, but not limited totheir use in other lung diseases, such as chronic obstructive pulmonary disease, are considered investigational.
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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.
- S8185 for the Flutter device
- E0480 for Percussor device, electric or pneumatic, home model
- E0481 for intrapulmonary percussive ventilation system and related accessories
- E0482 for cough stimulating device, alternating positive and negative airway pressure (mechanical insufflation-exsufflation)
- E0483 for high frequency chest wall oscillation air-pulse generator system (includes hoses and vest), each
- E0484 for oscillatory positive pressure device, non-electric, any type, each
- A7025 High frequency chest wall oscillation system vest
- A7026 High frequency chest wall oscillation system hose
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Selected References:
- The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
- A review of the medical literature and recommendations from the Medical Policy Advisory Council (MPAC), which assists Wellmark’s medical directors in the development of medical policies. MPAC is comprised of practicing physicians from Iowa and South Dakota.
- KatkinJp. Cystic Fibrosis. Rakel, ed, Conn's Current Therapy 199, 51st edition.
W.B. Saunders Co. 58:1999
- Derdak S. et. Al. High-frequency oscillatory ventilation for acute respiratory distress syndrome in adults. Am J Respir Crit Care Med 2002;166:801-808.
- Bellone A et. Al. Chest physical therapy in patients with acute exacerbation of chronic bronchitis: effectiveness of three methods. Arch Phys Med Rehabil 2000;81:558-560.
- Jones AP, Rowe BH. Bronchopulmonary hygiene physical therapy for chronic obstructive pulmonary disease and bronchiectasis (Chochrane Review) In: the Chochrane Library, Issue 4.2002. Oxford: Update Software.
- Silverman E, et al. Current management of bronchiectasis: review and 3 case studies. Heart Lung. 2003 Jan-Feb;32(1):59-64.
- Varekojis SM, et al. A comparison of the therapeutic effectiveness of and preference for postural drainage and percussion, intrapulmonary percussive ventilation, and high-frequency chest wall compression in hospitalized cystic fibrosis patients. Respir Care. 2003 Jan;48(1):20-1
- McCool, FD, Rosen, MJ. Nonpharmacologic airway clearance therapies: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 Suppl):250S-259S.
- Kendrick A, Airway clearance techniques in cystic fibrosis: physiology, devices and the future. Journal of the Royal Society of Medicine. 2007; 100(Suppl. 47)3-23
- Marks J. Airway clearance devices in cystic fibrosis. Paediatric Respiratory Reviews 2007; 8 17-23.
- Myers TR, Positive Expiratory Pressure and Oscillatory Positive Expiratory Pressure Therapies. Respiratory Care 10/2007, 52(10) 1308-1327.
- ECRI. Mechanical Insufflation-Exsufflation for Respiratory Insufficiency. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2011 March 21. (ECRI Hotline Response). Also available: http:/www.ecri.org.
- ECRI. High Frequency Chest Compression for Cystic Fibrosis and Other Pulmonary Conditions. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2011 March 21. (ECRI Hotline Response). Also available: http:/www.ecri.org.
- Pryor JA, Tannenbaum E, Scott SF, et al. Beyond postural drainage and percussion: Airway clearance in people with cystic fibrosis. J Cyst Fibros. 2010 May;9(3):187-92.
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Policy History:
Date Reason Action
October 2010 Annual review Policy renewed
November 2011 Annual review Policy revised
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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 © 2010 American Medical Association. All Rights Reserved.
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