High frequency chest wall oscillation devices (HFCWO)(E0483) are covered for patients who meet:

A. Criteria 1, 2 or 3, and
B. Criteria 4.

1. There is a diagnosis of cystic fibrosis.
   
   
2. There is a diagnosis of bronchiectasis, which has been confirmed by a high resolution, spiral, or standard CT scan and which is characterized by:
   
   
   
   1. Daily productive cough for at least 6 continuous months; or
   2. Frequent (i.e., more than 2/year) exacerbations requiring antibiotic therapy.
      
      Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed diagnosis of bronchiectasis do not meet this criterion.
      
      
3. The patient has one of the following neuromuscular disease diagnoses:
   
   
   Post-polio
   Acid maltase deficiency
   Anterior horn cell diseases
   Multiple sclerosis
   Quadriplegia
   Hereditary muscular dystrophy
   Myotonic disorders
   Other myopathies
   Paralysis of the diaphragm
   
   
4. There must be well-documented failure of standard treatments to adequately mobilize retained secretions.
   

If all of the criteria are not met, the claim will be denied as not medically necessary.

It is not medically necessary for a patient to use both an HFCWO device and a mechanical in-exsufflation device (E0482). If the member meets the criteria for the high frequency chest wall oscillation device (E0483) and a mechanical in-exsufflation device (E0482) is also billed, the mechanical in-exsufflation device (E0482) will deny as not medically necessary.

NOTE:

For guidelines on oscillatory devices, including the in-exsufflator (E0482), see Medical Policy Bulletin E-1, Durable Medical Equipment (DME).

Replacement supplies, A7025 and A7026, used with patient owned equipment, are covered if the patient meets the criteria listed above for the base device, E0483. If these criteria are not met, claims will be denied as not medically necessary.

Documentation Requirements

Services that do not meet the medical necessity criteria on this policy will be considered not medically necessary. A participating, preferred or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Coverage for DME is determined according to individual or group customer benefits.

NOTE:

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

Description

A high frequency chest wall oscillation (HFCWO) device (e.g., ABI Vest Airway Clearance System, Thairapy Vest) is an airway clearance device consisting of an inflatable vest connected by tubes to a small air-pulse generator.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

DME MAC Jurisdiction A L12870

Yuan N, Kane P, Shelton K, Matel J, Becker BC, Moss RB.  Safety, tolerability, and efficacy of high-frequency chest wall oscillation in pediatric patients with cerebral palsy and neuromuscular diseases: an exploratory randomized controlled trial.  J Child Neurol. 2010 Jul;25(7):815-21.

Oermann CM, Sockrider MM, Giles D, Sontag MK, Accurso FJ, Castile RG.  Comparison of high-frequency chest wall oscillation and oscillating positive expiratory pressure in the home management of cystic fibrosis: a pilot study.  Pediatr Pulmonol. 2001 Nov;32(5):372-7.

Hess DR. The evidence for secretion clearance techniques.  Respir Care. 2001 Nov;46(11):1276-93.

Lester Mary K, RRT, Flume Patrick A, MD. Airway-clearance therapy guidelines and implementation.  Respiratory Care. June 2009. Vol 54; No 6.

Panitch Howard B, MD. Respiratory issues in the management of children with neuromuscular disease.  Respiratory Care. August 2006. Vol 51; No 8.