High Frequency Chest Wall Oscillation Devices

Policy ID: E-68-015

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: September 26, 2021

Revision Effective Date: October 01, 2023

Last Reviewed: November 15, 2023

Applies To: Commercial and Medicaid Expansion

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

High frequency chest wall oscillation devices (HFCWO) may be considered medically necessary for individuals when ANY of the following criteria are met:

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 six (6) continuous months; or
- Frequent (i.e., more than two (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 individual has one of the following neuromuscular disease diagnoses:
- Acid maltase deficiency (Pompe Disease); 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.

HFCWO devices not meeting criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

A7020

A7025

A7026

E0482

E0483

Replacement supplies used with individual owned equipment may be considered medically necessary if the individual 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

G71.20

G71.21

G71.220

G71.228

G71.29

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

J44.89

J47.0

J47.1

J47.9

J98.6

M33.02

M33.12

M33.22

M33.92

M34.82

M35.03

Q33.4

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-22-2020 Annual Review no changes in criteria

Internal Medical Policy Committee 9-21-2020 ICD-10 coding update

Removed Diagnosis code G71.2 and
Added Diagnosis codes G71.20; G71.21; G71.220; G71.228 and G71.29.

Internal Medical Policy Committee 9-21-2021

Removed Diagnosis code R48.0; and
Removed Policy Position; and
Added Procedure code A7020.

Internal Medical Policy Committee 9-28-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 11-15-2023 - Effective 10-01-2023

Added Diagnosis code J44.89

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: E-68-013

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: September 28, 2020

Revision Effective Date: November 02, 2020

Last Reviewed: September 21, 2020

Archived Date: October 31, 2021

Applies To: Commercial Only

Description

Criteria

High frequency chest wall oscillation devices (HFCWO) may be considered medically necessary for individuals 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 six (6) continuous months; or
- Frequent (i.e., more than two (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 individual 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 individual 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 individual owned equipment are considered medically necessary if the individual 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

G71.20

G71.21

G71.220

G71.228

G71.29

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

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-22-2020 Annual Review no changes in criteria

Internal Medical Policy Committee 9-21-2020 ICD-10 coding update; removed Diagnosis code G71.2 and added G71.20; G71.21; G71.220; G71.228 and G71.29.

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.

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