ModifiednorthwoodPolicy N/A

Airway Clearance Devices

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Defines medical necessity, coverage criteria, limitations, and coding for airway clearance devices (PEP, oscillating PEP, postural drainage board, percussor) for members with excessive respiratory secretions and impaired airway clearance. Affects treating practitioners, DME suppliers, and members receiving durable medical equipment services.

Policy Summary

Payernorthwood

PolicyAirway Clearance Devices

Policy CodePolicy N/A

Change TypeCodes addedExperimental device designation

Effective DateNov 1, 2021

Next Review DateNov 1, 2022

Key ActionSubmit prior authorization using current HCPCS codes and include the treating practitioner's order and necessary documentation of training when applicable.

SourceLink

POLICY UPDATE CHANGES

Added code E0606 postural drainage board to policy.

Added BiWaze clear system and its codes of A7021 and E0469 to policy as Experimental and Investigational.

Added code S8185 is a non-Medicare code (annotation).

Added NCD, LCD verbiage to 'Important Note'.

Added asthma to diagnosis examples list.

4device categories covered

6HCPCS codes listed

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ModifiednorthwoodPolicy N/A

Airway Clearance Devices

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Policy Summary

Payernorthwood

PolicyAirway Clearance Devices

Policy CodePolicy N/A

Change TypeCodes addedExperimental device designation

Effective DateNov 1, 2021

Next Review DateNov 1, 2022

Key ActionSubmit prior authorization using current HCPCS codes and include the treating practitioner's order and necessary documentation of training when applicable.

SourceLink

POLICY UPDATE CHANGES

Added code E0606 postural drainage board to policy.

Added BiWaze clear system and its codes of A7021 and E0469 to policy as Experimental and Investigational.

Added code S8185 is a non-Medicare code (annotation).

Added NCD, LCD verbiage to 'Important Note'.

Added asthma to diagnosis examples list.

4device categories covered

6HCPCS codes listed

recent codes added/flagged

4devices experimental

>=21change history entries

Coverage and Medical Necessity Criteria

Initial coverage criteria

Covered when ALL of the following are met:

General coverage: Device is one of the following: positive expiratory pressure device, oscillating positive expiratory pressure device, postural drainage board, or percussor.

Ordering requirement: Device is ordered by the member's treating practitioner.

Practitioner order required for listed HCPCS-coded devices and prior authorization where applicable.

Clinical indication: Member has a diagnosis characterized by excessive mucus production and difficulty clearing secretions.

Examples (not exhaustive) include: asthma; bronchiectasis; chronic bronchitis; chronic lower respiratory diseases; chronic obstructive asthma; chronic obstructive lung disease; congenital bronchiectasis; cystic fibrosis; disorders of the diaphragm; emphysema; lung transplant status; motor neuron disease; muscular dystrophies; myoneural disorders (ALS); obstructive chronic bronchitis; situs inversus (immotile cilia syndrome).

Percussor limitations

Provision and replacement limitations for percussor:

Percussor provision and replacement: Powered percussor is provided only when the member or operator has received appropriate training by a physician, treating practitioner, or therapist and no one is available to administer manual therapy. Repair of a percussor is covered to restore the device to a serviceable condition provided the damage is not the result of misuse (intentional or non-intentional) when member owned. Replacement of a percussor is covered when any of the following are met: (a) irreparable damage not due to misuse (intentional or non-intentional); (b) an irreparable change in the condition of the percussor; or (c) the cost of repairs would exceed the purchase price.

Documentation of training and demonstration that manual therapy is not available must be provided for powered percussor provision; repair vs replacement decisions follow the repair/replace threshold criteria.

The policy explicitly lists certain airway clearance technologies as experimental and investigational and therefore not eligible for coverage. Specifically, the policy names the Simeox Airway Clearance Technology bronchial drainage device, high-frequency chest compression systems for several indications (including anoxic brain injury, CFTR‑related metabolic syndrome, dyspnea in COPD, and plastic bronchitis), and the Volara System Oscillation & Lung Expansion (OLE) therapy device for asthma and middle lobe syndrome as experimental and investigational. These items are identified in the policy’s exclusions and should be treated as non-covered when submitted for benefit determination under this guideline.

The policy identifies the BiWaze Clear System as experimental and investigational and specifically annotates the associated HCPCS codes A7021 and E0469 as linked to that device. The change history documents the addition of the BiWaze Clear System and its codes to the policy as experimental and investigational on the 11‑3‑25 annual review; claims for devices billed with A7021 or E0469 should account for this experimental designation when determining coverage and prior authorization requirements.

The policy clarifies that equipment used primarily and customarily for a non‑medical purpose is not considered durable medical equipment (DME). Coverage determinations for such items are made on a case‑by‑case basis and remain subject to the member’s contract terms, limitations, and exclusions. In other words, even if a device appears in the policy, final benefit responsibility is defined by the member’s contract and plan language rather than by the policy alone.

Billing Codes and Coding Guidance

HCPCS Level II CodesHCPCS

A7021	Supplies and accessories for lung expansion airway clearance, continuous high frequency oscillation, and nebulization device (e.g., handset, nebulizer kit, biofilter).
E0469	Lung expansion airway clearance, continuous high frequency oscillation, and nebulization device.
E0480	Percussor, electric or pneumatic, home model.
E0484	Oscillatory positive expiratory pressure device, nonelectric, any type, each.
E0606	Postural drainage board.
S8185	Flutter device (non-Medicare code).

Codes added / annotated in change historyHCPCS | mixed

E0606	postural drainage board (added to policy)
A7021	BiWaze clear system (listed as Experimental and Investigational)
E0469	BiWaze clear system (listed as Experimental and Investigational)
S8185	non-Medicare code (annotation in change history)

Percussor repair vs replace threshold

Repair coverage conditionRepair is covered to restore a Percussor to serviceable condition when the damage is not the result of misuse (intentional or non‑intentional).

Replacement coverage conditionsReplacement is covered when (a) irreparable damage not due to misuse; (b) an irreparable change in the condition of the Percussor; or (c) the cost of repairs would exceed the purchase price.

Powered percussor provision requirementA powered Percussor is provided only when the member or operator has received appropriate training by a physician, treating practitioner, or therapist and no one is available to administer manual therapy.

Orders, Documentation, and Provider Responsibilities

Prior Authorization

Practitioner order required for HCPCS‑coded devices

Devices referenced by HCPCS codes in this policy (E0480, E0484, E0606, E0469, A7021, S8185) require a practitioner order from the member's treating practitioner before coverage will be considered.

Order must be from the member's treating practitioner as stated in coverage criteria.

Billing Rule

Use current codes and note experimental status

Prior authorization and claim submissions should use the current HCPCS code list in the policy; change history records addition of E0606 and later designation of A7021 and E0469 as Experimental and Investigational.

Background and Scope

Airway clearance devices are intended to assist members with respiratory disorders that produce excessive secretions and impaired airway clearance. These devices work by loosening thick mucus to facilitate expectoration: for example, positive expiratory pressure (PEP) devices increase resistance to expiratory airflow to prevent airway closure and improve collateral ventilation; oscillating PEP devices add high‑frequency oscillations to that positive pressure to mobilize secretions; and adjunctive devices such as postural drainage boards and percussors mobilize secretions and provide percussion when clinically indicated. Use is targeted to members whose diagnoses result in difficulty clearing secretions and who have a treating practitioner’s order documenting medical necessity.

Device Definitions

PEP device — definition and mechanism

DefinitionPositive expiratory pressure (PEP) device: increases resistance to expiratory airflow to promote mucus clearance by preventing airway closure and increasing collateral ventilation.

MechanismCreates expiratory resistance so airways remain open during exhalation, improving collateral ventilation and facilitating expectoration of secretions.

Examples noted in policyTheraPEP, Resistex PEP Mask, Pari RC Cornet Mucus Clearing Device.

Oscillating PEP device — definition and examples

DefinitionOscillating positive expiratory pressure (PEP) device: a form of PEP that combines high‑frequency airflow oscillations with positive expiratory pressure via a small handheld device.

PurposeUses combined oscillation and positive pressure to assist mucus clearance by loosening secretions and promoting expectoration.

Policy Summary

Payernorthwood

PolicyAirway Clearance Devices

Policy CodePolicy N/A

Change TypeCodes addedExperimental device designation

Effective DateNov 1, 2021

Next Review DateNov 1, 2022

Key ActionSubmit prior authorization using current HCPCS codes and include the treating practitioner's order and necessary documentation of training when applicable.

SourceLink

On This Page

Added code E0606 to policy (change history entry 11-4-24).

A7021 and E0469 were later added and flagged as Experimental and Investigational (change history entry 11-3-25).

Documentation Required

Percussor repair, replacement requirements

Replacement or repair of a percussor requires documentation that the device damage is not due to misuse and either can be restored to serviceable condition (repair) or meets replacement criteria (irreparable damage or change, or repair cost exceeds purchase price).

Repair covered to restore to serviceable condition if damage is not from misuse (member‑owned).
Replacement covered when: (a) irreparable damage not due to misuse; (b) irreparable change in condition; or (c) repair cost would exceed purchase price.

Note

Include order and qualifying diagnosis

Ensure a treating‑practitioner order is submitted and include the qualifying diagnosis; lack of either may lead to non‑coverage or denial.

Coverage criteria require both an order and a diagnosis characterized by excessive mucus production and difficulty clearing secretions.

Documentation Required

Required order and powered percussor training documentation

The device must be ordered by the member's treating practitioner; for a powered percussor, include documentation that the member or operator received appropriate training by a physician, treating practitioner, or therapist and that no one is available to provide manual therapy.

Order from the member's treating practitioner is required.
For powered percussor, document training and lack of available manual therapy per policy limitations.

Billing Rule

Provide documentation to support coding

When submitting claims, reference the policy's updated code list and recent change history entries (e.g., added diagnosis examples, coding annotations) to support correct coding and diagnosis mapping.

Change history documents additions to diagnosis examples and coding annotations—confirm you are using the current policy code list (see HCPCS codes).

Denial Risk

Order and qualifying diagnosis required to avoid denial

Absence of a treating‑practitioner order or of a qualifying diagnosis (excessive mucus production with difficulty clearing secretions) may result in denial of coverage.

Ensure documentation shows the member meets the policy’s clinical criteria to avoid denials.

Denial Risk

Experimental device — denial risk for A7021 / E0469

Devices listed as Experimental and Investigational (for example, the BiWaze Clear System identified by codes A7021 and E0469) are at risk for denial if submitted for coverage.

BiWaze Clear System and codes A7021 and E0469 were explicitly added as Experimental and Investigational in the change history.

ExamplesFlutter and Acapella devices (policy examples).

Postural drainage board — definition and intended use

DefinitionPostural drainage board: device used to assist in mobilizing respiratory tract secretions for members with chronic pulmonary conditions.

Intended useUsed to position the patient to facilitate gravity‑assisted drainage of secretions from specific lung segments.

Coding noteAdded to policy as HCPCS code E0606 (postural drainage board).

Percussor — definition, powered options

DefinitionPercussor: device used for percussion for diagnoses requiring percussion, consisting of a hammer with a rubber or metal head; powered percussors may be electric or pneumatic.

Powered optionsPowered Percussor may be electric or pneumatic and is subject to provision limits requiring documented training and lack of available manual therapy.

Repair/replacement rulesRepair covered if restorable and not due to misuse; replacement when irreparable, irreparable condition change, or repair cost exceeds purchase price.

Airway clearance devices — umbrella term

Umbrella definitionAirway clearance devices: includes positive expiratory pressure devices, oscillating devices (e.g., Flutter, Acapella), mechanical percussive/vest devices, and adjunctive devices such as postural drainage boards.

PurposeAssist members with respiratory disorders characterized by excessive secretions and impaired airway clearance by loosening thick mucus to facilitate expectoration.

Policy examplesDevices cited in policy include TheraPEP, Resistex PEP Mask, Pari RC Cornet, Flutter, Acapella, percussors, and postural drainage boards.