ModifiedColorado Rocky Mountain Health PlansPolicy CS054OH.D

Airway Clearance Devices (for Ohio Only)

Medical policy governing coverage and medical necessity of airway clearance devices (e.g., high-frequency chest wall oscillation, intrapulmonary percussive ventilation, and combination oscillation and lung expansion devices) for members in Ohio.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAirway Clearance Devices (for Ohio Only)

Policy CodePolicy CS054OH.D

Change TypeDocumentation requirements addedevidence section updated

Effective DateJun 1, 2026

Next Review Date

Key ActionProvide complete, legible medical record documentation (history, physical exam, diagnostic test results) upon request to substantiate medical necessity.

SourceLink

POLICY UPDATE CHANGES

Medical records documentation requirements used for reviews were added, clarifying that documentation may be required to assess whether the member meets clinical criteria and must support medical necessity.

Notation added that coverage will remain consistent with the Ohio Department of Medicaid Fee for Service Fee Schedule.

Clinical evidence section was updated to reflect more current information.

6HCPCS codes listed in policy

OhioGeographic application

Not medically necessaryCoverage stance for combination OLE devices

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Coverage Criteria

inv-01: Combination OLE devices — Not medically necessary

Policy coverage stance and references

Not medically necessary for combination OLE devices: Combination continuous PEP, continuous high-frequency oscillation, and nebulized medication therapy devices for oscillation and lung expansion (OLE) are considered unproven and not medically necessary due to insufficient quality evidence or consistency of findings.

Supported by policy statement and evidence summary.

inv-02: HFCWO devices — follow Ohio Administrative Code criteria

Referenced coverage pathways for specific device categories

HFCWO devices: Medical necessity clinical coverage criteria for high-frequency chest wall oscillation (HFCWO) devices are determined by the Ohio Administrative Code Rule 5160-10-08.

Providers must follow the Ohio Administrative Code criteria.

inv-03: Intrapulmonary percussive ventilation — InterQual criteria

Referenced clinical criteria source for intrapulmonary percussive ventilation

Intrapulmonary percussive ventilation: Medical necessity clinical criteria for an intrapulmonary percussive ventilation (IPV) system are determined by InterQual CP: Durable Medical Equipment, Airway or Secretion Clearance Devices.

Policy directs to InterQual for specific clinical criteria.

Coverage limitations and exclusions for durable medical equipment, prostheses, orthoses, and supplies (DMEPOS) referenced in this policy follow Ohio Administrative Code Rule 5160-10-01 (DMEPOS: General Provisions) and Rule 5160-10-02 (DMEPOS: Repair). Providers should consult these OAC rules for specific exclusion and repair provisions that apply to DME items discussed in this policy.

No additional coverage limitations or exclusions are specified in this portion of the medical policy. When applying this policy, always confirm federal, state (Ohio Administrative Code), or contractual requirements as they govern in the event of a conflict with the policy text.

Requests for combination devices that provide continuous positive expiratory pressure (PEP), continuous high-frequency oscillation, and concurrent nebulized medication therapy (termed OLE devices) are considered not medically necessary. The policy states that, due to insufficient quality evidence or consistency of findings, these combination oscillation and lung expansion devices are unproven and not medically necessary for oscillation and lung expansion indications.

This section of the document does not contain explicit additional 'not medically necessary' statements beyond the device-specific determinations already provided elsewhere in the policy. Use the device-specific coverage stance and referenced OAC/InterQual criteria when assessing medical necessity.

Coding

Applicable HCPCS codes referencedHCPCS

A7021	Supplies and accessories for lung expansion airway clearance, continuous high frequency oscillation, and nebulization device (e.g., handset, nebulizer kit, biofilter).
A7025	High frequency chest wall oscillation system vest, replacement for use with patient- owned equipment, each.
A7026	High frequency chest wall oscillation system hose, replacement for use with patient- owned equipment, each.
E0469	Lung expansion airway clearance, continuous high frequency oscillation, and nebulization device.
E0481	Intrapulmonary percussive ventilation system and related accessories.
E0483	High frequency chest wall oscillation system, with full anterior and/or posterior thoracic region receiving simultaneous external oscillation, includes all accessories and supplies, each.

Provider Actions and Policy Requirements

Prior Authorization

Prior Authorization and Criteria Sources

Prior authorization is required. Coverage determinations reference the Ohio Administrative Code (OAC) and InterQual® criteria as primary sources for medical necessity review. Providers must obtain prior authorization before delivering HFCWO or intrapulmonary percussive ventilation devices when required by the member's benefit. Failure to secure required prior authorization may result in claim denial or member liability.

Affected codes include: E0469, E0481, E0483, A7021, A7025, A7026

Note

Reference Requirements for Coverage Determination

When deciding coverage, federal law, state law (Ohio Administrative Code), or the terms of the payer contract take precedence. If there is a conflict between this policy and federal, state (OAC), or contractual requirements, those federal/state/contractual requirements govern. Providers must verify and follow applicable federal, state (OAC), and contractual coverage rules for each member prior to service.

Medical Necessity

inv-20: DME medical necessity criteria references

Criteria sourcing for specific DME items

HFCWO: Follow Ohio Administrative Code Rule 5160-10-08 for HFCWO medical necessity criteria.

Policy defers to state rule for detailed criteria.

IPV: Follow InterQual CP: Durable Medical Equipment, Airway or Secretion Clearance Devices for intrapulmonary percussive ventilation criteria.

Policy references InterQual for IPV criteria.

inv-21: Indications — Device indicated when external chest manipulation is physician's treatment of choice

Device is indicated when external chest manipulation is the physician's treatment of choice to enhance mucus transport and promote airway clearance.

Indication for HFCWO:

Rental and Purchase Rules

Equipment / Item	Rental vs Purchase Rule (Ohio)	Notes
General DME items including HFCWO and related supplies
Refer to Ohio Administrative Code Rule 5160-10-01 for DMEPOS general provisions; rental versus purchase determinations follow the Ohio Administrative Code
See Applicable Codes for HCPCS references; coverage and payment follow the Ohio Department of Medicaid Fee for Service Fee Schedule

Equipment / Item	Rental vs Purchase Rule (Ohio)	Notes
High-frequency chest wall oscillation (HFCWO) devices (vest systems, hoses, accessories)
Not specified in this policy excerpt; follow Ohio Administrative Code Rule 5160-10-08 for device-specific medical necessity and applicable procurement rules
Applicable HCPCS codes: E0483, A7025, A7026 (see policy applicable codes); documentation requirements updated 06/01/2026 may be requested to substantiate medical necessity

Replacement

Replacement provisions (unspecified)

Replacement interval specifiedNot specified in this portion of the document.

Operational notePolicy history indicates replacement intervals and equipment-specific rules remain governed by Ohio Administrative Code and fee schedule guidance as applicable.

Documentation requirement relatedMedical records documenting medical necessity must be legible and available upon request and may be used to assess need for replacements or repairs.

Documentation Requirements

Documentation Required

Document history, exam, and diagnostic results in the medical record

Ensure the patient’s medical record documents relevant history, physical examination, and pertinent diagnostic test results to support medical necessity for the requested DME.

Documentation should be comprehensive, legible, and maintained in the patient’s medical record.

Documentation Required

Provide complete medical records that fully support medical necessity

Medical records submitted for review must fully support the medical necessity of the requested service and may be requested at any time; include relevant history, physical exam, and results of pertinent diagnostic tests or procedures.

Ensure records are legible and complete because documentation may be required to assess whether the member meets clinical criteria.
Maintain and provide records promptly when requested to avoid delays.

Background

High-frequency chest wall compression / high-frequency chest wall oscillation (HFCWO) devices are external systems designed to promote airway clearance and improve bronchial drainage through high-frequency compression/oscillation of the chest wall. Evidence comparing oscillatory airway clearance devices to other techniques is limited; clinicians should follow the policy’s referenced criteria (including state rules and external clinical guidance) when considering these devices.

Definitions

HFCWO — definition

TermHFCWO (High-Frequency Chest Wall Compression Devices)

DefinitionDevices designed to promote airway clearance and improve bronchial drainage via high-frequency chest wall compression/oscillation.

IndicationIndicated when external chest manipulation is the physician's treatment of choice to enhance mucus transport.

Regulatory referenceFDA product code reference provided for additional device information (product code BYI).

High-Frequency Chest Wall Compression Devices (HFCWO) — purpose and indications

Primary mechanismPromote airway clearance through high-frequency chest wall compression/oscillation.

Not Covered

Combination continuous PEP, continuous high-frequency oscillation, and nebulized medication therapy devices (OLE devices) are specifically identified in this policy as not covered because they are considered unproven. Coverage determinations for these combination devices should be denied consistent with the policy’s statement that available evidence is insufficient to support medical necessity.

This portion of the policy does not list any additional explicit durable medical equipment exclusions for HFCWO systems. Providers must reference Ohio Administrative Code and the policy’s device-specific statements when determining coverage for HFCWO equipment and supplies.