E0459, Chest wrap
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documented diagnosis of one of the covered conditions: central hypoventilation, chest wall deformity, or slowly progressive neuromuscular disease (examples: muscular dystrophy, poliomyelitis, multiple sclerosis, spinal cord disease, diaphragmatic paralysis).
- Evidence of chronic stable or slowly progressive respiratory failure with objective testing as applicable: arterial blood gas showing PaCO2 > 50 mm Hg (significant CO2 retention) OR PaCO2 > 45 mm Hg plus clinical symptoms or nocturnal testing.
- If PaCO2 is between >45 and ≤50 mm Hg, documentation of symptoms attributable to hypoventilation (cognitive dysfunction, daytime hypersomnolence, or morning headache) OR documented nocturnal hypoventilation/oxygen desaturation defined as oxyhemoglobin saturation < 88% for at least 5 minutes.
Key Coverage Criteria
- A second invasive or non-invasive ventilator is considered medically necessary if it is required to serve a different purpose as determined by the member’s medical needs (examples include needing one ventilator type for part of the day and a different type for the rest of the day; or wheelchair-mounted ventilator plus a second ventilator for use in bed).
- CPT/HCPCS: CPT 94662 (Continuous negative pressure ventilation (CNP), initiation and management) and HCPCS E0457 (Chest shell (cuirass)) and E0459 (Chest wrap) are covered if selection criteria are met.
- Non-invasive negative pressure ventilation (body ventilators, poncho wrap) is medically necessary durable medical equipment (DME) for members with stable or slowly progressive respiratory failure due to neuromuscular diseases, chest wall deformity, or central hypoventilation syndromes.
- Members with central hypoventilation (i.e., apnea not due to airway obstruction).
- Members with chest wall deformity (e.g., post-thoracoplasty for tuberculosis, etc.).
- Members with slowly progressive neuromuscular diseases (examples listed: muscular dystrophies, poliomyelitis, multiple sclerosis, spinal cord diseases, diaphragmatic paralysis).
1 Active Policy
AETNA-CPB-0298, Non-invasive Negative Pressure Ventilation: Body Ventilators and Poncho Wrap
Related Codes
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