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

Chest physiotherapy (CPT) or percussion and postural drainage (P/PD) is the most commonly used and effective secretion clearance technique. There are several types of devices and breathing methods intended to promote the clearance of respiratory secretions and are used passively or actively by the individual. The devices may be designed as a vest, flutter valve, or as a percussive ventilator. The devices may be referred to as oscillatory devices, high-frequency chest compression devices or mucus clearance devices.

The high frequency chest wall oscillation system (e.g., the Vest Airway Clearance System®, formerly known as the ThAIRapy Vest® or the ABI Vest®) is a portable device that provides external thoracic percussion. It consists of a non-stretching inflatable vest linked to an air pulse generator 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. This airway clearance therapy is commonly referred to as high frequency chest wall oscillation. It is not position dependent for mucus clearance.

The oscillatory positive expiratory pressure devices (e.g., FLUTTER® and Acapella devices) is a small pipe-shaped, portable hand-held device, with a mouthpiece at one end. It 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. The Acapella type device is similar in concept but uses a counterweighted plug and magnet to create air flow oscillation.

The intrapulmonary percussive ventilator (IPV) provides internal thoracic percussion by self-administered chest physiotherapy for airway clearance. It is a form of oscillating positive expiratory pressure device. IPV combines internal thoracic percussion through rapid mini-bursts of inhaled air through a mouthpiece and continuous therapeutic aerosol delivered through a nebulizer. Upon expiration, the individual coughs to assist in eliminating secretions. The purpose of the treatment is for therapeutic mobilization of retained endobronchial secretions and resolution of diffuse patchy atelectasis.

POLICY

See also: Mechanical In-Exsufflator (Cough Machine)

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Requests for the bronchial drainage system vest should be referred to the Case Management Department for review. For review purposes, consider how often chest physiotherapy has been ordered [e.g., if the order is for chest physiotherapy more than 2 times per day, and the caregiver is at work 8 hours a day, the bronchial drainage system vest may be medically appropriate]. Documentation that less intensive treatments have been tried and failed may be further evidenced by repeated courses of home antibiotic infusion therapy due to problematic secretions, and/or recurrent hospitalizations for respiratory exacerbations.

The Vest Airway Clearance System® now includes a lifetime warranty covering: parts, labor, vest refits, and accessories. Individuals will be responsible only for shipping and handling charges incurred more than two years after initial shipment of the vest system. There is insufficient data to show the efficacy of the use of the bronchial drainage system vest for other diseases/conditions.

The intrapulmonary percussive ventilator device is investigated as an alternative (not adjunct) to conventional chest physical therapy. Data has failed to demonstrate improved outcome when compared with alternative pulmonary care techniques.

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 May 3, 2013 from BlueWeb. (13 articles and/ or guidelines reviewed)

BlueCross BlueShield of Tennessee network physicians.  August 2005.

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

Center for Medicare Services, CIGNA Government Services. Local Coverage Determinations (LCDs). (May, 2013). LCD for high frequency chest oscillation devices (HFCWO) (L12934). Retrieved May 16, 2013 from http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=12934&ContrId=140&ver=27&ContrVer=2&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Tennessee&KeyWord=high+frequency&KeyWordLookUp=Title&KeyWordSearchType=And&from2=search.asp&bc=gAAAABAAAAAAAA%3d%3d&.

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.

Noridian Medicare Service.  Local Coverage Determinations (LCDs). (May, 2013). LCD for intrapulmonary percussive ventilation (L11573). Retrieved May 16, 2013 from www.noridianmedicare.com

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. 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. (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. (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)

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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