CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for High Frequency Chest Wall Oscillation Air-Pulse Generator System (Vest)

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This guideline governs MassHealth medical-necessity determinations and prior authorization for a high frequency chest wall oscillation air-pulse generator system used for airway-clearance therapy. It applies to MassHealth providers, including Oxygen and Respiratory Therapy Equipment providers, submitting requests for eligible members.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyHigh Frequency Chest Wall Oscillation Air-Pulse Generator System (Vest)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 22, 2022

Next Review DateN/A

Key ActionSubmit prior authorization and supporting documentation through the MassHealth Durable Medical Equipment and Oxygen Payment and Coverage Guideline Tool.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PA required

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CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for High Frequency Chest Wall Oscillation Air-Pulse Generator System (Vest)

Customize your policy alerts

Sign up for all Massachusetts Executive Office of Health and Human Services policy alerts

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Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyHigh Frequency Chest Wall Oscillation Air-Pulse Generator System (Vest)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 22, 2022

Next Review DateN/A

Key ActionSubmit prior authorization and supporting documentation through the MassHealth Durable Medical Equipment and Oxygen Payment and Coverage Guideline Tool.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PA required

20–30 minTypical treatment duration

6 monthsProductive cough criterion

>2/yearExacerbation criterion

1/5 yearsGenerator replacement

1/3 yearsVest and hose replacement

Coverage Criteria

Initial Vest Therapy Coverage

Covered when all of the following are met.

Vest medical necessity

Qualifying diagnosis
- Cystic fibrosis: Diagnosis of cystic fibrosis.
- Bronchiectasis pathway
  - Bronchiectasis confirmation: Diagnosis confirmed by a high-resolution, spiral, or standard CT scan of the chest.
  - Bronchiectasis clinical criterion
    Productive cough: Daily productive cough for at least 6 continuous months.at least 6 continuous months
    Frequent exacerbations requiring antibiotic and mechanical airway-clearance therapy.more than 2 per year
- Neuromuscular disease pathway: Diagnosis of a neuromuscular disease affecting the ability to cough or clear respiratory secretions, including acid maltase deficiency, anterior horn cell diseases, hereditary muscular dystrophy, multiple sclerosis, myotonic disorders, paralysis of the diaphragm, post-polio syndrome, quadriplegia, or other myopathies.
Contraindications addressed: The member has no absolute contraindication, and relative contraindications have been fully addressed by a medical provider.
Absolute contraindications are unstable head or neck injury and active hemorrhage with hemodynamic instability. Relative contraindications are lung contusion, rib osteomyelitis, rib fracture, osteoporosis, coagulopathy, and chest wall pain.
Failure of standard treatment: There is well-documented failure of standard treatment for clearance and mobilization of retained secretions, including suction, cough assist with cough track technology, manual chest physiotherapy, manual or electric percussors, PEP or flutter devices, and inhaled mucolytics.
Caregiver limitation: There is well-documented lack of caregiver ability to perform chest physiotherapy at the required frequency resulting in recurrent infection or hospitalization related to the underlying disease.

Vest use is not covered when an absolute contraindication is present, including an unstable head or neck injury or active hemorrhage with hemodynamic instability.

Chronic lung disease, including chronic bronchitis or chronic obstructive pulmonary disease (COPD), is not eligible for Vest coverage when a confirmed diagnosis of bronchiectasis is absent.

MassHealth does not consider a Vest medically necessary when manual chest physiotherapy or another less costly and effective therapy is available.

Covered Codes and Billing Limits

Covered High Frequency Chest Wall Oscillation SystemHCPCSCovered

E0483

High frequency chest wall oscillation air pulse generator system, includes all accessories and supplies, each.

Covered Replacement ComponentsHCPCSCovered

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.

Daily productive cough

Qualifying conditionBronchiectasis

Required durationDaily productive cough for at least 6 continuous months

Clinical pathwayThe cough criterion applies when bronchiectasis is confirmed by a high-resolution, spiral, or standard CT scan of the chest

Bronchiectasis exacerbations

Qualifying conditionBronchiectasis

Required frequencyMore than 2 exacerbations per year

Treatment requirement

Provider Actions

Prior Authorization

Prior Authorization Required

MassHealth requires prior authorization (PA) for a High Frequency Chest Wall Oscillation Air-Pulse Generator System (Vest). Requests must be submitted by an eligible MassHealth provider of Oxygen and Respiratory Therapy Equipment, and PA is reviewed on the basis of medical necessity.

Prior Authorization

Use the Designated Submission Channel

Submit all information supporting the Vest PA request through the applicable MassHealth channel. Electronic requests should be submitted through the Long-Term Services and Supports (LTSS) Management System (LTMS), or through the Provider Online Service Center (POSC) for Community Case Management (CCM) members.

For a non-electronic request, mail the PA-1 form and supporting documentation to the address on the back of the form.
LTMS access questions: MassHealth LTSS Provider Service Center, 1-844-368-5184.
POSC access questions: MassHealth Customer Service Center, (800) 841-2900.

Clinical Background

Patients with cystic fibrosis, bronchiectasis, neuromuscular disorders, or impaired secretion clearance may be at increased risk for pneumonia and other respiratory complications related to retained secretions. High frequency chest wall oscillation therapy may be considered when conventional or conservative airway-clearance therapy has failed.

Definitions

Airway Clearance Therapy (ACT)

TermAirway Clearance Therapy (ACT)

DefinitionTreatment intended to loosen, mobilize, and remove retained respiratory secretions

ExampleChest physiotherapy, including manual percussion and vibration of the chest

High Frequency Chest Wall Oscillation (HFCWO)

TermHigh Frequency Chest Wall Oscillation (HFCWO)

Therapy definitionAn inflatable vest connected to an air-pulse generator delivers high-frequency compression pulses to the chest wall

Mechanism

Medical Necessity Determination

Vest System Medical Necessity

The equipment is medically necessary when all applicable clinical criteria are met.

DME medical necessity: The member has a qualifying diagnosis, no absolute contraindication, addressed relative contraindications, documented failure of standard airway-clearance treatment, and documented caregiver inability when applicable.

See the Initial Vest Therapy Coverage criteria for the qualifying diagnosis pathways and detailed requirements.

Replacement Frequency

High frequency chest wall oscillation air-pulse generator system (E0483)

HCPCS codeE0483

EquipmentHigh frequency chest wall oscillation air pulse generator system, including all accessories and supplies

Replacement frequency1 per 5 years

High frequency chest wall oscillation system vest (A7025)

HCPCS codeA7025

EquipmentHigh frequency chest wall oscillation system vest, replacement for use with patient-owned equipment

Replacement frequency

Required Documentation

Documentation Required

Submit complete medical-necessity documentation with the PA request

The PA request must include a written prescription and letter of medical necessity signed by the ordering practitioner, together with clinical documentation supporting the qualifying diagnosis, secretion-clearance impairment, failed therapies, treatment history, laboratory information, cough ability, and Vest trial.

The prescription and letter must meet 130 CMR 427.408.
Supporting clinical documentation must meet 130 CMR 450.204 and 450.303.

Documentation Required

Document the Vest trial and therapeutic response

Document a trial of the Vest device as part of the PA request, including clinical assessments before, during, and after therapy and the member’s response to treatment.

Breath sounds before, during, and after Vest therapy.
Cough assessment.
Member tolerance and therapeutic settings.
Physical Therapy Evaluation of the Vest trial.

Not Covered Services and Conditions

Vest use is not covered for chronic bronchitis or COPD without a confirmed diagnosis of bronchiectasis, when manual chest physiotherapy or another less costly and effective therapy is available, or when an absolute contraindication is present, including unstable head or neck injury or active hemorrhage with hemodynamic instability.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyHigh Frequency Chest Wall Oscillation Air-Pulse Generator System (Vest)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 22, 2022

Next Review DateN/A

Key ActionSubmit prior authorization and supporting documentation through the MassHealth Durable Medical Equipment and Oxygen Payment and Coverage Guideline Tool.

SourceLink

On This Page

Each exacerbation must require antibiotic and mechanical airway-clearance therapy

E0483 frequency limit

HCPCS codeE0483

Unit definition1 unit = each

Replacement limit1 per 5 years

A7025 and A7026 replacement frequency limit

HCPCS codesA7025 and A7026

Unit definition1 unit = each

Replacement limit1 per 3 years

Documentation Required

Document Failure of Standard Airway-Clearance Therapy

Document well-documented failure of standard treatment for clearance and mobilization of retained secretions before requesting a Vest.

Suction machine
Cough assist with cough track technology
Manual chest physiotherapy (CPT)
Manual or electric percussor
Positive Expiratory Pressure (PEP) devices or flutter valves
Inhaled mucolytics

Documentation Required

Document Caregiver Limitations

Document a well-documented lack of caregiver ability to perform CPT at the required frequency, together with recurrent infection or hospitalization related to the underlying disease.

Describe the caregiver limitation and the required CPT frequency.
Link the limitation to recurrent infection or hospitalization.

Documentation Required

Submit Clinical Medical-Necessity Documentation

The PA request must include clinical documentation supporting medical necessity for the Vest. Documentation must establish the qualifying diagnosis, impaired mucus clearance and unmanageable secretions, failure of standard airway-clearance and other treatment modalities, and the member’s clinical ability to expectorate secretions.

Prescribing provider documentation of a qualifying diagnosis.
History of impaired mucus clearance and unmanageable secretions.
Use and failure of standard airway-clearance options.
Use and failure of other treatment modalities, including inhaled antibiotic regimens, mucolytic agents, and expectorants.
Frequency of antibiotic use during the previous year.
Sputum sample laboratory results from the previous three months.
Evidence that the member has a strong enough cough to expectorate secretions.

Documentation Required

Document the Vest Trial

Document that the member trialed a Vest device and include pre-, during-, and post-therapy clinical assessments and the response to therapy.

Breath sounds before, during, and after Vest therapy.
Cough assessment.
Member tolerance of the trial and therapeutic settings.
Physical Therapy Evaluation of the Vest trial.

Unsupported block type: documentation

Denial Risk

No Confirmed Bronchiectasis

A Vest is not considered medically necessary for chronic lung disease, including chronic bronchitis or chronic obstructive pulmonary disease (COPD), when there is no confirmed diagnosis of bronchiectasis.

Denial Risk

Less Costly Effective Therapy Available

A Vest is not considered medically necessary when manual CPT or another less costly and effective therapy is available.

Denial Risk

Screen for Contraindications

Do not pursue Vest use when an absolute contraindication is present. The member must also have any relative contraindications fully addressed by a medical provider.

Absolute contraindications: unstable head or neck injury; active hemorrhage with hemodynamic instability.
Relative contraindications requiring medical-provider assessment: lung contusion, osteomyelitis of the ribs, rib fracture, osteoporosis, coagulopathy, or chest wall pain.

Documentation Required

Establish All Core Coverage Criteria

Before submitting a PA request, establish the core coverage criteria: a qualifying diagnosis, no absolute contraindication with relative contraindications addressed, and documented failure of standard secretion-clearance treatment or inability of the caregiver to provide CPT at the required frequency resulting in recurrent infection or hospitalization.

Qualifying diagnoses include cystic fibrosis; confirmed bronchiectasis meeting the applicable clinical criteria; or a neuromuscular disease affecting the ability to cough or clear respiratory secretions.
For bronchiectasis, document confirmation by chest CT and either daily productive cough for at least six continuous months or more than two exacerbations per year requiring antibiotics and mechanical airway-clearance therapy.
For neuromuscular disease, examples include acid maltase deficiency, anterior horn cell diseases, hereditary muscular dystrophy, multiple sclerosis, myotonic disorders, paralysis of the diaphragm, post-polio syndrome, quadriplegia, and other myopathies.

The compressions change airway volume and flow, helping loosen and mobilize secretions to the large airways for removal by coughing or suctioning

High Frequency Chest Compression (HFCC) device

TermHigh Frequency Chest Compression (HFCC) device

DefinitionAn FDA-cleared device used as an alternative airway-clearance therapy

ApplicabilityAvailable for selected individuals described in the guideline; prior authorization should be submitted by a MassHealth provider of Oxygen and Respiratory Therapy Equipment

High frequency chest wall oscillation system hose (A7026)

HCPCS codeA7026

EquipmentHigh frequency chest wall oscillation system hose, replacement for use with patient-owned equipment

Replacement frequency1 per 3 years