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).

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. (6:2016). Oscillatory devices for the treatment of cystic fibrosis and other respiratory disorders (1.01.15). Retrieved December 29, 2016 from BlueWeb. (18 articles and/ or guidelines reviewed)

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

Center for Medicare and Medicaid Services. CMS.gov. LCD for high frequency chest wall oscillation devices (L33785). Retrieved December 29, 2016 from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33785.

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

Cystic Fibrosis Foundation. (April, 2016). Clinical practice guidelines from the Cystic Fibrosis Foundation for preschoolers with cystic fibrosis. Retrieved December 30, 2016 from the National Guideline Clearinghouse (NGC: 010964).

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. (Level 1 evidence - Independent)

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.

Lee, A. L., Burge, A. T., & Holland, A. E. (2015). Airway clearance techniques for bronchiectasis. Cochrane Database System Review, 2015, (11). Abstract retrieved January 3, 2017 from PubMed database.

McIlwaine, M., Button, B., & Dwan, K. (2015). Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis. Cochrane Database System Review, 2015, (6). Abstract retrieved January 3, 2017 from PubMed database.

Morrison, L., & Agnew, J. (2014). Oscillating devices for airway clearance in people with cystic fibrosis. Cochrane Database System Review, 2014, (7). Abstract retrieved January 3, 2017 from PubMed database.

Panitch, H. (2006). Respiratory issues in the management of children with neuromuscular disease. Respiratory Care, 51 (8), 885-896. (Level 5 evidence - Independent)

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., De Win, H., Steens, M., & Soudon, P. (2003). Effect of intrapulmonary percussive ventilation on 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; last update search December 2016). High-frequency chest wall compression for cystic fibrosis. Retrieved December 30, 2016 from www.Hayesinc.com (77 articles and/or guidelines reviewed)

Winifred S. Hayes. Medical Technology Directory. (2014, March; last update search March 2016). High-frequency chest wall compression for diseases other than cystic fibrosis. Retrieved December 30, 2016 from www.Hayesinc.com (57articles 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:  2/9/2017

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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