BlueCross BlueShield of Tennessee Medical Policy Manual

Mechanical In-Exsufflator (Cough Machine)

DESCRIPTION

The mechanical in-exsufflator, or cough machine, is a portable machine intended to stimulate a cough for individuals unable to cough or clear secretions effectively. It works by gradually applying a positive pressure to the airway, then rapidly shifting to a negative pressure. The rapid shift in pressure, via facemask or mouthpiece, produces a high expiratory flow rate from the lungs. A cough is stimulated, which assists in clearing broncho-pulmonary secretions.

POLICY

• The mechanical in-exsufflator, when used as an alternative to tracheostomy or other invasive procedures, is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

• Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.

MEDICAL APPROPRIATENESS

• The mechanical in-exsufflator, when used as an alternative to tracheostomy or other invasive procedures, is considered medically appropriate with ALL the following:

• • Inability to cough or clear secretions effectively due to reduced peak cough expiratory flow (less than two to three liters per second)

  • Inability to successfully and adequately mobilize retained secretions with standard treatments such as chest percussion and postural drainage

  • The individual has a high spinal cord injury, or a neuro-muscular deficit, or severe fatigue associated with intrinsic lung disease

IMPORTANT REMINDERS

• Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.

• We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

ADDITIONAL INFORMATION

Careful consideration should be given before the mechanical in-exsufflator is used for individuals with any of the following conditions: History of bullous emphysema; known susceptibility to pneumothorax or pneumo-mediastinum; or known to have had a recent barotrauma.

SOURCES

BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2004). Mechanical insufflation-exsufflation as a expiratory muscle aid (1.01.21). Retrieved April 2, 2012 from BlueWeb. (12 articles and/or guidelines reviewed)

Finder, J. D. (2010). Airway clearance modalities in neuromuscular disease. Paediatric Respiratory Reviews, 11 (1), 31-34.

Guerin, C., Bourdin, G., Leray, V., Delannoy, B., Bayle, F., Germain, M., et al. (2011). Performance of the coughassist insufflation-exsufflation device in the presence of an endotracheal tube or tracheostomy tube: A bench study. Respiratory Care, 56 (8), 1108-1114.

Homnick, D. N. (2007). Mechanical insufflation-exsufflation for airway mucus clearance. Respiratory Care, 52 (10), 1296-1305.

Miller, R. G., Jackson, C. E., Kasarskis, E. J., England, J. D., Forshew, D., Johnston, W., et al. (2009). Practice parameter update: The care of the patient with amyotrophic lateral sclerosis: Drug, nutritional, and respiratory therapies (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 73 (15), 1218-1226.

National Guideline Clearinghouse. (2010, July). Motor neurone disease. The use of non-invasive ventilation in the management of motor neurone disease. Retrieved April 2, 2012 from http://www.guidelines.gov.

Striegl, A. M., Redding, G. J., Diblasi, R., Crotwell, D., Salyer, J., & Carter, E. R. (2011). Use of a lung model to assess mechanical in-exsufflator therapy in infants with tracheostomy. Pediatric Pulmonology, 46, 211-217.

Toussaint, M. (2011). The use of mechanical insufflation-exsufflation via artificial airways. Respiratory Care, 56 (8), 1217-1219.

U. S. Food and Drug Administration (2008, January). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K072292. Retrieved April 2, 2012 from http://www.accessdata.fda.gov/cdrh_docs/pdf7/K072292.pdf.

ORIGINAL EFFECTIVE DATE:  1/8/1998

MOST RECENT REVIEW DATE:  5/10/2012

ID_BA

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.

This document has been classified as public information.