Īetna considers mechanical in-exsufflation devices medically necessary DME for persons with a neuromuscular disease (e.g., amyotrophic lateral sclerosis, congenital myopathies, inclusion body myositis, muscular dystrophy, myasthenia gravis, poliomyelitis, progressive bulbar palsy, spinal muscular atrophy, high spinal cord injury with quadriplegia) that is causing a significant impairment of chest wall and/or diaphragmatic movement and for whom standard treatments (e.g., chest percussion and postural drainage, etc.) have not been successful in adequately mobilizing retained secretions.Īetna considers the following devices or interventions experimental and investigational because the effectiveness of these approaches has not been established: Lung transplant recipients, within the first 6 months post-operatively, who are unable to tolerate standard chest physiotherapy. Quadriplegia regardless of underlying etiology.Anterior horn cell diseases, including amyotrophic lateral sclerosis or.The member has one of the following neuromuscular disease diagnoses:.

Cystic fibrosis or immotile cilia syndrome.Bronchiectasis, confirmed by CT scan, characterized by daily productive cough for at least 6 continuous months or by frequent (i.e., more than 2 times/year) exacerbations requiring antibiotic therapy.Positive expiratory pressure (PEP) mask for CF, chronic bronchitis, immotile cilia syndrome, asthma, and chronic obstructive pulmonary disease (COPD) Īetna considers high-frequency chest compression systems (e.g., the AffloVest, the Frequencer, the Monarch Airway Clearance System, the SmartVest, the MedPulse Respiratory Vest System, the Vest Airway Clearance System, the ABI Vest, Respin11 Bronchial Clearance System, and the InCourage Vest/System) medically necessary DME in lieu of chest physiotherapy for the following indications, where there is a well documented failure of standard treatments to adequately mobilize retained secretions:.Mechanical percussors (e.g., Fluid Flo, Frequencer, and VibraLung Acoustical Percussor) for CF, chronic bronchitis, bronchiectasis, immotile cilia syndrome, and asthma.Airway oscillating devices (e.g., Flutter and Acapella) for cystic fibrosis (CF), chronic bronchitis, bronchiectasis, immotile cilia syndrome (also known as primary ciliary dyskinesia) and asthma.Note: Chest physiotherapy by a respiratory therapist is not considered medically necessary for persons whose pulmonary condition is stable, as chest physiotherapy can be competently administered at home by a family member or caregiver.Īetna considers the following airway clearance devices medically necessary durable medical equipment (DME) to assist in mobilizing respiratory tract secretions for members with the conditions that are indicated below: Chest physiotherapy when the member’s pulmonary condition is unstable.Home chest physiotherapy upon the initial prescription of chest physiotherapy to stabilize the member and to train family members or caregivers to administer chest physiotherapy.

This Clinical Policy Bulletin addresses chest physiotherapy and airway clearance devices.Īetna considers the folowing interventions by a respiratory therapist medically necessary: (Replaces CPBs 252, 280, 333) Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References

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