A4468 — Exsufflation belt, includes all supplies and accessories
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Objective documentation of nocturnal desaturation (e.g., oxyhemoglobin saturation ≤ 88% for ≥ 5 minutes) or daytime hypercapnia (PaCO2 ≥ 45 mm Hg) to justify NPPV initiation.
- For neuromuscular disease: pulmonary function test results (e.g., FVC % predicted, with FVC < 50% frequently preceding symptomatic involvement) and/or maximal inspiratory pressure (MIP < 60 cm H2O) as indicators of nocturnal desaturation risk.
- For COPD: baseline PaCO2 values (with PaCO2 ≥ 55 mm Hg identifying subgroups more likely to benefit in some trials) and documentation of nocturnal desaturation and degree of compliance and IPAP settings if claiming benefit.
- Physician re-assessment of benefit and adherence within 60 days of therapy initiation (methods include patient interview, awake arterial blood gas values, and overnight oximetry while using the NPPV therapy).
Key Coverage Criteria
- Covered ICD-10 diagnoses (listed as covered if selection criteria are met): "B91; E66.2; G12.0-G12.9; G14; G47.31; G47.33; G47.35; G47.36; G47.37; G54.0-G54.9; G55; G70.00-G73.7; G93.31-G93.39; J39.8; J40-J44.9; J47.0-J47.9; J67.0-J67.9; J80; J96.00-J96.92; J98.4; M41.00-M41.9; M96.5; M95.4; Q32.0; Q67.8; R06.00-R06.9; R09.02; R53.0-R53.1; R53.81; R58.83; numerous options for late effect of spinal cord injury (codes not listed due to expanded specificity).
- Support of chronic and acute ventilatory failure with noninvasive positive-pressure ventilation (NPPV) delivered by a nasal or facemask (bilevel PAP ventilator).
- Restrictive thoracic diseases, including thoracic cage abnormalities (e.g., chest wall deformities, kyphoscoliosis, thoracoplasty) and neuromuscular disorders (e.g., amyotrophic lateral sclerosis (ALS), neuropathies, myopathies, dystrophies, sequelae of polio, spinal cord injury) that cause hypoventilation.
- Patients with symptoms attributable to nocturnal hypoventilation and objective findings of nocturnal desaturation (e.g., clinically significant nocturnal hypoxemia defined as oxyhemoglobin saturation ≤88% for at least 5 minutes).
- Patients with PaCO2 ≥ 45 mm Hg (consensus panel suggested this as a sufficient indication for NPPV).
- Progressive neuromuscular disorders with pulmonary function test indicators of nocturnal desaturation (examples: forced vital capacity (FVC) below 50% predicted; maximal inspiratory pressure < 60 cm H2O as a sensitive indicator).
2 Active Policies
AETNA-CPB-0452 — Noninvasive Positive Pressure Ventilation
ANTHEM-DME.00046 — DME.00046 Intermittent Abdominal Pressure Ventilation Devices
Related Codes
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