BlueCross BlueShield of Tennessee Medical Policy Manual

Percussion / Oscillating Devices for the Treatment of Respiratory Conditions

DESCRIPTION

This policy addresses the use of percussive oscillating devices in the outpatient setting only

Percussion and oscillating devices can be used as an alternative to the standard daily percussion and postural drainage method of airway clearance for patients with Cystic Fibrosis. There are several types of devices and breathing methods intended to promote the clearance of respiratory secretions that are used passively or actively by the individual. These devices have also been proposed for other respiratory conditions such as chronic obstructive pulmonary disorder (COPD).

The high frequency chest wall percussion system (e.g., the Vest Airway Clearance System®, manufactured by Hill-Rom) is a portable device that provides external thoracic percussion. It consists of a non-stretching inflatable vest linked to an air pulse generator connected by two flexible hoses. The generator rapidly inflates and deflates the vest, gently compressing and releasing the chest wall to create airflow within the lungs. This process moves mucous toward the larger airways where it can be cleared by coughing. It is not position dependent for mucus clearance.

The oscillatory positive expiratory pressure devices (e.g., FLUTTER®; Acapella®) are small pipe-shaped, portable hand-held devices, with a mouthpiece at one end. One contains a high-density stainless steel ball that rests in a plastic circular cone. During exhalation, the steel ball moves up and down, creating oscillations in expiratory pressure and airflow. When the oscillation frequency approximates the resonance frequency of the pulmonary system, vibration of the airways occurs, resulting in loosening of mucus. Another device is similar in concept but uses a counterweighted plug and magnet to create air flow oscillation.

The intrapulmonary percussive ventilator (IPV) device (e.g.,Percussionaire IVP®) is a form of oscillating positive expiratory pressure that provides internal thoracic percussion that is also self-administered. IPV combines internal thoracic percussion through rapid mini-bursts of inhaled air through a mouthpiece and continuous therapeutic aerosol nebulizer. Upon expiration, the individual coughs to eliminate secretions. The purpose of the treatment is to remove retained endobronchial secretions and resolve atelectasis.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Members with requests for the bronchial drainage system vest should be referred to the Case Management / Population Health areas for potential assistance.

The use of high-frequency chest wall compression and home use of intrapulmonary percussive ventilation devices in other chronic pulmonary diseases, such as chronic obstructive pulmonary disorder, is considered investigational due to insufficient evidence on the impact of treatment on health outcomes.

SOURCES

American Academy of Neurology. (2009). Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: drug, nutritional, and respiratory therapies (an evidence based review). Retrieved May 3, 2013 from www.guideline.gov

American Association for Respiratory Care (AARC). (1991). AARC clinical practice guideline. Postural drainage therapy. Retrieved August 19, 2011 from http://www.aarc.org/resources/protocol_resources/documents/broncho_hygiene_algorithm.pdf.

BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2012). Oscillatory devices for the treatment of cystic fibrosis and other respiratory disorders (1.01.15). Retrieved October 6, 2014 from BlueWeb. (5  articles and/ or guidelines reviewed)

Bricker & Eckler Attorneys at Law. (2014) Home Health Care Reform for Providers: Face to Face Encounter With the Patient Required Before Physicians May Certify Eligibility for Home Health Services or Durable Medical Equipment Section 6407 - Patient Protection and Affordable Care Act. Retrieved October 7, 2014 from http://www.bricker.com/services/resource-details.aspx?resourceid=568 .

British Thoracic Society. (2012). Guideline for respiratory management of children with neuromuscular weakness. Retrieved May 3, 2013 from www.guideline.gov .

Complete Guide to Medicare Coverage Issues [Computer software]. (2012, November). Intrapulmonary percussive ventilator (IPV) (NCD 240.5, p. 2-209). OptumInsight.

Cystic Fibrosis Foundation. (2010, April). Airway clearance techniques. Retrieved August 19, 2011 from: http://www.cff.org/treatments/Therapies/Respiratory/AirwayClearance/.

ECRI Institute. Health Technology Information Service. Evidence Reports. (2000, October).High-frequency chest compression for cystic fibrosis. Retrieved August 19, 2011 from ECRI Institute. (34 articles and/or guidelines reviewed)

Flume, P. A., Robinson, K. A., O’Sullivan, B. P., Finder, J. D., Vender, R. L., Willey-Courand, et al. (2009). Cystic fibrosis pulmonary guidelines: Airway clearance therapies. Respiratory Care, 54 (4), 522-537.

Keating, J., Collins, N., Bush, A., & Chatwin, M. (2011). High-frequency chest wall oscillation in a noninvasive ventilation dependent patient with type 1 spinal muscular atrophy. Respiratory Care, 56 (11), 1840-1844. (Level 4 Evidence - Independent)

Kempainen, R., Milla, C., Dunitz, J., Savik, K., Hazelwood, A., Williams, C., et al. (2010). Comparison of settings used for high-frequency chest-wall compression in cystic fibrosis. Respiratory Care, 55 (6), 695-701. (Level 3 Evidence - Industry sponsored)

Kennedy, J., & Martin, A. (2009). Chronic respiratory failure and neuromuscular disease. Pediatric Clinics of North America, 56 (1), 261-273.

Panitch, H. (2006). Respiratory issues in the management of children with neuromuscular disease. Respiratory Care, 51 (8), 885-896.

Sontag, M. K., Quittner, A. L., Modi, A. C., Koenig, J. M., Giles, D., Oermann, C. M., et al. (2010). Lessons learned from a randomized trial of airway secretion clearance techniques in cystic fibrosis. Pediatric Pulmonology, 45 (3), 291-300. (Level 2 Evidence - Industry sponsored)

Toussaint, M., DeWin, H., Steens, M., & Soudon, P. (2003). Effect of intrapulmonary percussive ventilationon mucous clearance in Duchenne muscular dystrophy patients: A preliminary report. Respiratory Care, 48 (10), 940-948. (Level 3 Evidence- Independent)

U. S. Department of Health & Human Services. Centers for Medicare & Medicaid Services. Local Coverage Determination. (July 2013). LCD: High Frequency Chest Wall Oscillation Devices (L12934) Retrieved October 6, 2014 from http://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=255.

U. S. Food and Drug Administration. (2005, December). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K053248. Retrieved August 19, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf5/K053248.pdf.

U. S. Food and Drug Administration. (2007, March). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K063645. Retrieved August 19, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf6/K063645.pdf.

U. S. Food and Drug Administration. (2010, January). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K091557. Retrieved August 19, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf9/K091557.pdf.

Winifred S. Hayes. Medical Technology Directory. (2011, September). High-frequency chest wall compression for diseases other than cystic fibrosis. Retrieved April 5, 2013 from www.Hayesinc.com/subscribers. (60 articles and/or guidelines reviewed)

Winifred S. Hayes. Medical Technology Directory. (2012, May). High-frequency chest wall compression for cystic fibrosis. Retrieved April 5, 2013 from www.Hayesinc.com/subscribers. (56 articles and/or guidelines reviewed)

Winifred S. Hayes. Medical Technology Directory. (2014, May). Update: High-frequency chest wall compression for diseases other than cystic fibrosis. Retrieved October 6, 2014 from www.Hayesinc.com/subscribers.  (2 articles and/or guidelines reviewed)

Yuan, N., Kane, P., Shelton, K., Matel, J., Becker, B., & Moss, R. (2010). Safety, tolerability, and efficacy of high-frequency chest wall oscillation in pediatric patients with cerebral palsy and neuromuscular diseases: an exploratory randomized controlled trial. Journal of Child Neurology, 25 (7), 815-821. (Level 3 Evidence - Industry sponsored)

ORIGINAL EFFECTIVE DATE:  10/25/2001

MOST RECENT REVIEW DATE:  9/11/2013

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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