Our Member Services Representatives are unavailable Friday, April 10, due to the holiday.

 

CORONAVIRUS (COVID-19)

Resources on COVID-19 and how BCBSND is responding to help protect all North Dakotans

High Frequency Chest Wall Oscillation Devices

Section: Durable Medical Equipment
Effective Date: June 30, 2018
Revised Date: May 13, 2018
Last Reviewed: July 16, 2019

Description

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

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

High frequency chest wall oscillation devices (HFCWO) may be considered medically necessary for patients who meet the following:

  • Diagnosis of cystic fibrosis; or
  • Diagnosis of bronchiectasis, which has been confirmed by CT scan which is characterized by:
    • Daily productive cough for at least 6 continuous months; or
    • 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); or
  • The patient has one of the following neuromuscular disease diagnoses:
    • Post-polio; or
    • Acid maltase deficiency; or
    • Anterior horn cell diseases; or
    • Multiple sclerosis; or
    • Quadriplegia; or
    • Hereditary muscular dystrophy; or
    • Myotonic disorders; or
    • Other myopathies; or
    • Paralysis of the diaphragm; and
  • There must be well-documented failure of standard treatments to adequately mobilize retained secretions or valid reasons why standard chest physiotherapy cannot be performed (such as inability of caregiver to perform), is unavailable or not tolerated.

Procedure Codes

A7025 A7026 E0482 E0483

Use of both an HFCWO device and a mechanical in-exsufflation device is considered not medically necessary. If the member meets the criteria for the high frequency chest wall oscillation device and a mechanical in-exsufflation device is also billed, the mechanical in-exsufflation device will be considered not medically necessary.

Replacement supplies used with patient owned equipment are considered medically necessary if the patient meets the criteria listed above for the base device.

Diagnosis Codes

A15.0 B91 D81.810 D84.1 E84.0 E84.9 G12.0
G12.1 G12.8 G12.9 G12.20 G12.21 G12.22 G12.29
G14 G35 G71.0 G71.00 G71.01 G71.02 G71.09
G71.2 G71.3 G71.8 G71.11 G71.12 G71.13 G71.14
G71.19 G72.0 G72.1 G72.2 G72.89 G73.7 G82.50
G82.51 G82.52 G82.53 G82.54 J47.0 J47.1 J47.9
J98.6 M33.02 M33.12 M33.22 M33.92 M34.82 M35.03
Q33.4 R48.0

Links