E0484 — Oscillatory positive expiratory pressure device, non-electric, any type, each
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For high-frequency chest compression systems: documentation of 'well-documented failure of standard treatments' to adequately mobilize retained secretions is required (i.e., evidence that standard treatments have been attempted and were inadequate).
- For bronchiectasis indication: CT scan confirmation of bronchiectasis; clinical characterization of bronchiectasis (daily productive cough for at least 6 continuous months OR frequent exacerbations >2/year requiring antibiotic therapy).
- For device coverage in neuromuscular disease: documentation of the specific neuromuscular diagnosis and evidence that the disease is causing significant impairment of chest wall and/or diaphragmatic movement; documentation that standard treatments (e.g., chest percussion and postural drainage) have not been successful in adequately mobilizing retained secretions.
Key Coverage Criteria
- 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.
- Mechanical percussors (e.g., Fluid Flo, Frequencer, VibraLung Acoustical Percussor) as medically necessary DME for: cystic fibrosis, chronic bronchitis, bronchiectasis, immotile cilia syndrome, and asthma.
- Positive expiratory pressure (PEP) mask as medically necessary DME for: cystic fibrosis, chronic bronchitis, immotile cilia syndrome, asthma, and chronic obstructive pulmonary disease (COPD).
1 Active Policy
AETNA-CPB-0067 — Chest Physiotherapy and Airway Clearance Devices
Related Codes
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