E0469 — Lung expansion airway clearance, continuous high frequency oscillation, and nebulization device
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; refer to the guidelines titled Medical Records Documentation Used for Reviews.
- For medical necessity determination of ongoing use, refer to the InterQual® criteria (Durable Medical Equipment, Secretion Clearance Devices (Custom) - UHG).
- For bronchiectasis: presence must be confirmed and classified radiographically by high resolution, spiral, or standard computed tomography (CT) scan (policy definition).
- For clinically significant bronchiectasis, documentation should show at least two of the following: a cough most days of the week, sputum production most days of the week, a history of exacerbations (policy definition).
Key Coverage Criteria
- G35.D Multiple sclerosis, unspecified
- G71.00 Muscular dystrophy, unspecified
- Z99.11 Dependence on respirator [ventilator] status
- G12.22 Progressive bulbar palsy
- G12.25 Progressive spinal muscle atrophy
- G12.8 Other spinal muscular atrophies and related syndromes
4 Active Policies
UHC-POL-airway-clearance-devices — Airway Clearance Devices
ANTHEM-MP-A050283 — Action
UMR-POL-UMR-airway-clearance-devices — Airway Clearance Devices
SUREST-POL-SUREST-airway-clearance-devices — Airway Clearance Devices
Related Codes
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