E0481, Intrapulmonary percussive ventilation system and related accessories
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Documentation Required
- A Standard Written Order (SWO) must be communicated to the supplier before claim submission for items addressed in this policy.
- For DMEPOS base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed WOPD before delivery; the WOPD must list the base item and may list separately billed associated options, accessories, and supplies.
- Suppliers are required to maintain proof of delivery (POD) documentation in their files and must provide POD to the Medicare contractor upon request.
- Claims must be correctly coded according to CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, and DME MAC articles; inadequate coding documentation may result in denial.
Key Coverage Criteria
- An item is covered only if it is in a defined Medicare benefit category, is reasonable and necessary for diagnosis/treatment or to improve function of a malformed body member, and meets all other applicable Medicare statutory and regulatory requirements.
- High-frequency chest wall oscillation (HFCWO) system rental for 2 months is medically necessary for management of neuromuscular diseases, bronchiectasis, and cystic fibrosis when criteria are met.
- Flutter / Acapella Device - ICD-10 codes covered if selection criteria are met : Q89.3 Quantitative Pupillometry/Pupillography
- 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.
- Chest physiotherapy when the member’s pulmonary condition is unstable.
- Airway oscillating devices (e.g., Flutter and Acapella) as medically necessary DME to assist in mobilizing respiratory tract secretions for members with: cystic fibrosis (CF), chronic bronchitis, bronchiectasis, immotile cilia syndrome (primary ciliary dyskinesia), and asthma.
13 Active Policies
ANTHEM-MP-A050283, Action
L33786, Intrapulmonary Percussive Ventilation System
UHC-POL-airway-clearance-devices, Airway Clearance Devices
AETNA-CPB-0067, Chest Physiotherapy and Airway Clearance Devices
BCBSIL-DME101.027, Airway Clearance Devices
Related Codes
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