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Medical Policy: 01.01.01
Original Effective Date: February 1995
Reviewed: November 2007
Revised: April 2004
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
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. 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
- Flutter device
- Positive expiratory pressure
- Intrapulmonary percussive ventilator
- Mechanical insufflation – exsufflation device
Policy:
One of the following devices may be considered medically necessary for the conditions listed below:
- High frequency oscillatory air chest compression devices may be covered for cystic fibrosis and bronchiectasis.
- Mechanical percussors: for cystic fibrosis, chronic bronchitis and bronchiectasis.
- Flutter 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.
Prior approval is recommended. Submit a prior approval now.
The intrapulmonary percussive ventilator device is considered not medically necessary.
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Procedure Codes and Billing
Guidelines:
- To report provider services, use appropriate CPT** codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- HCPCS code S8185 for the Flutter device
- HCPCS code E0480 for Percussor device, electric or pneumatic, home model
- HCPCS code E0481 for intrapulmonary percussive ventilation system and related accessories
- HCPCS code E0482 for cough stimulating device, alternating positive and negative airway pressure (mechanical insufflation-exsufflation)
- HCPCS code E0483 for high frequency chest wall oscillation air-pulse generator system (includes hoses and vest), each
- HCPCS code E0484 for oscillatory positive pressure device, non-electric, any type, each
- HCPCS code A7025 High frequency chest wall oscillation system vest
- HCPCS code 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
- 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.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave.
Des Moines, IA 50309
*Prior Approval is recommended for this policy.
**Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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.
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