This policy addresses the use of percussive oscillating devices in the outpatient setting onlyPercussion 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.
High frequency chest wall oscillation system (e.g., the Vest Airway Clearance System®, formerly known as the ThAIRapy Vest® or the ABI Vest®) for the treatment of compromised airway clearance associated with cystic fibrosis, bronchiectasis, or neuromuscular conditions (e.g. Duchenne Muscular Dystrophy) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Hand held oscillatory positive expiratory pressure devices (e.g. Flutter ®, Acapella®) for the treatment of compromised airway clearance associated with cystic fibrosis, bronchiectasis, or neuromuscular conditions (e.g. Duchenne Muscular Dystrophy) are considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Intrapulmonary percussive ventilation, in the home setting, as an alternative to chest physiotherapy, is considered not medically necessary.
High frequency chest wall oscillation system (e.g., the Vest Airway Clearance System®, formerly known as the ThAIRapy Vest® or the ABI Vest®) for the treatment of other conditions/diseases is considered investigational.
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
Percussion and/or oscillating devices for the treatment of compromised airway clearance are considered medically appropriate for ALL of the following are met:
No absolute contraindications for external manipulation of the thorax including ABSENCE of ALL the following:
Complaint of chest wall pain
Unstable head and/or neck pain
Recent epidural spinal infusion or spinal anesthesia
Recent skin grafts, or flaps, on the thorax
Burns, open wounds and skin infections of the thorax
Recently placed transvenous pacemaker or subcutaneous pacemaker
Osteomyelitis of the ribs
Active hemorrhage with hemodynamic instability
Suspected pulmonary tuberculosis
Treatment is indicated using ANY ONE of the following:
Hand-held oscillatory positive expiratory pressure device with ALL of the following:
Documented diagnosis of bronchiectasis, cystic fibrosis or a neuromuscular disease (e.g., Duchenne Muscular Dystrophy) that requires assisted mucus clearing
Conventional therapy has been tried and failed, including, but not limited to chest physical therapy
Device is used as an alternative to conventional chest physical therapy
High-frequency chest wall oscillation system with ANY ONE of the following:
Cystic fibrosis with ALL of the following:
Individual is 2 years old or greater
Documentation that less intensive treatments have been tried and failed (e.g., chest physical therapy and/or the electric home model percussor [E0480])
Inability of caregiver to provide effective chest drainage as prescribed
Bronchiectasis with ALL of the following:
Individual is 2 years old or greater
Documentation of daily productive cough for at least six continuous months
Frequent (i.e., more than 2 years) exacerbations requiring antibiotic therapy
Confirmed diagnosis by high resolution, spiral, or standard CT scan
Documented failure of standard treatments to adequately mobilize retained secretions
Neuromuscular diseases (e.g. Duchenne Muscular Dystrophy) with ALL of the following:
Individual is 2 years old or greater
Documentation of ineffective clearance of airway mucous
Documentation that less intensive treatments have been tried and failed (e.g., chest physical therapy)
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.
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.
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BlueCross BlueShield Association. Medical Policy Reference Manual. (6:2017). Oscillatory devices for the treatment of cystic fibrosis and other respiratory disorders (1.01.15). Retrieved December 1, 2017 from BlueWeb. (19 articles and/ or guidelines reviewed)
Cahaba Government Services, LLC. CMS.gov. (2017, October) Local coverage determination (LCD) for high frequency chest wall oscillation devices (L33785). Retrieved December 1, 2017 from https://www.cms.gov.
Chakravorty, I., Chahal, K., Austin, G. (2011, November) A pilot study of the impact of high-frequency chest wall oscillation in chronic obstructive pulmonary disease patients with mucus hypersecretion. International Journal of COPD, 2011 (6), 693-699. (Level 2 evidence)
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ORIGINAL EFFECTIVE DATE: 10/25/2001
MOST RECENT REVIEW DATE: 1/25/2018
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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