CurrentTexas Children's Health PlanPolicy 10577

Secretion and Mucous Clearance Devices Guideline

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This guideline governs Texas Children's Health Plan authorization and medical-necessity review for secretion and mucous clearance devices, including cough augmentation, HFCWO, IPV, electrical percussors, and IPPB devices. It also identifies devices that do not require prior authorization and establishes rental, purchase, replacement, and recertification requirements.

Policy Summary

PayerTexas Children's Health Plan

PolicySecretion and Mucous Clearance Devices Guideline

Policy CodePolicy 10577

Change TypeNo material change

Effective DateAug 31, 2023

Next Review DateN/A

Key ActionSubmit the required physician-completed prior-authorization form and clinical medical-necessity documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5Device categories requiring prior authorization

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CurrentTexas Children's Health PlanPolicy 10577

Secretion and Mucous Clearance Devices Guideline

Customize your policy alerts

Sign up for texaschildrenshealthplan Policy 10577 alerts

Get alerted when Policy 10577 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerTexas Children's Health Plan

PolicySecretion and Mucous Clearance Devices Guideline

Policy CodePolicy 10577

Change TypeNo material change

Effective DateAug 31, 2023

Next Review DateN/A

Key ActionSubmit the required physician-completed prior-authorization form and clinical medical-necessity documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5Device categories requiring prior authorization

Device categories not requiring prior authorization

3 monthsCommon initial rental period

10 monthsRental-to-purchase period

<270 lpmPeak cough flow threshold

50%HFCWO compliance minimum

Coverage Criteria

General Medical Necessity

A secretion and mucus clearance device may be considered medically necessary when documentation clearly shows that the member has at least one of the following:

ONE of the following

Evidence of retained respiratory secretions.
Evidence that the member has difficulty clearing respiratory secretions.
Atelectasis caused by mucus plugging.

Cough Augmentation — Initial Rental

A cough augmentation device (mechanical insufflator-exsufflator or cough assist machine; E0482) may be considered for an initial three-month rental when ALL applicable requirements are met:

ALL of the following

The member has chronic pulmonary disease or a neuromuscular disorder, including but not limited to spinal cord injury with quadriplegia, muscular dystrophy, or spinal muscular atrophy, affecting the respiratory musculature and causing a weak, ineffectual, or absent cough.
The treating physician submits documentation that is completed, signed, and dated, including diagnosis and medical history, recent illnesses, complications, medications, recent hospitalizations, and pulmonary function study results when applicable.
Clinical evidence supports natural deterioration to the level requiring cough augmentation to clear the airways, such as pulmonary function studies or peak cough flow assessing cough strength in an adolescent or adult with a result below 270 L/min.< 270 L/min
Documentation explains why the member's parent, guardian, or caregiver cannot perform chest physiotherapy or why those therapies were previously ineffective.
Following the initial three-month trial, the treating physician documents compliance with equipment use and treatment effectiveness for continued rental.
For continued rental through an out-of-network provider, the request is limited to up to 90 days and documents either that the provider was in-network when the initial rental was requested or that the member received the services under prior authorization from another Managed Care Organization or Fee-for-Service provider.

HFCWO — Initial Rental

An HFCWO system (CPT Vest; E0483) may be considered for an initial three-month rental when ALL applicable requirements are met:

ALL of the following

HFCWO is not being requested as first-line treatment; the member has trialed other percussion and postural drainage therapy for at least three months before the request, and the documentation explains why prior therapy was ineffective. An exception may be considered for cystic fibrosis or bronchiectasis with chronic mucopurulent bronchitis.
ONE qualifying condition
- Bronchiectasis confirmed by CT scan and characterized by either a continuous daily productive cough for six months or frequent pulmonary infection exacerbations, more than twice per year, requiring antibiotic therapy.
- Cystic fibrosis or other documented chronic suppurative endobronchitis.
- A chronic neuromuscular disorder affecting the member's ability to cough or clear respiratory secretions.

HFCWO — Purchase After Rental

After the initial three-month rental, purchase of an HFCWO system may be considered when ALL applicable requirements are documented:

ALL of the following

The HFCWO system therapy results are submitted and document that the system is effective.
Effectiveness and tolerance are documented, including evidence of vest tolerance.
The treating physician provides a description and assessment of effectiveness and tolerance, including the member's diagnosis and respiratory-related history.
The documentation shows respiratory-related complications and a decrease in those complications.
The documentation addresses recent hospitalizations related to the respiratory condition and shows shorter hospital lengths of stay and decreased hospitalizations.

IPV — Initial Rental

An intrapulmonary percussive ventilation (IPV) system (E0481) may be considered for an initial three-month rental when ALL applicable requirements are met:

ALL of the following

HFCWO is contraindicated, and the member has chronic pulmonary disease or a neuromuscular disorder, including spinal cord injury with quadriplegia, affecting the respiratory musculature and causing a weak, ineffectual, or absent cough.
ONE qualifying condition
- Bronchiectasis confirmed by CT scan and characterized by either a continuous daily productive cough for six months or frequent pulmonary infection exacerbations, more than twice per year, requiring antibiotic therapy.
- A history of chronic respiratory illness with inability to adequately clear respiratory secretions, leading to complications such as chronic bronchitis or recurrent pneumonia.
Other appropriate chest physiotherapy, based on age, ability, and skill, such as percussion and postural drainage therapy or a mechanical device, was trialed by the member's parent, guardian, or caregiver for at least three months, and the request documents why the therapy was ineffective or contraindicated.

An IPV system is not a benefit when requested primarily for the convenience of the caregiver.

A member generally may not have both an HFCWO system and an IPV system because the devices have similar actions on mucus clearance. An exception may be considered with a detailed letter of medical necessity from the treating pulmonologist describing how a purchased device failed to meet the member's airway-clearance needs and why the other device is medically necessary; during the rental period, one device must be discontinued to obtain the other. A member with severe neuromuscular disease, ineffective cough, and recurrent pneumonia may require both cough assist and HFCWO or IPV when the treating pulmonologist documents the recurrent pneumonia, ineffective cough, and need to loosen mucus for adequate clearance.

IPPB is not the therapy of first choice for delivering aerosol or providing lung hyperinflation when other therapies can reliably meet the member's prescribed clinical objectives. Rental of an IPPB device includes all supplies, including humidification and tubing.

Medical Necessity Framework

General DME Medical Necessity

Covered when at least one qualifying secretion-clearance problem is documented:

ONE of

Evidence of retained respiratory secretions.
Evidence that the member has difficulty clearing respiratory secretions.
Atelectasis caused by mucus plugging.

Device-Specific DME Criteria

The general medical-necessity requirement must be met. In addition, the requested device must meet ALL applicable device-specific requirements:

ALL applicable:

Covered Device Coding and Thresholds

Devices not requiring prior authorizationHCPCSCovered

A9284	Incentive spirometers
S8185	Mucous clearance valved chamber; oscillating positive expiratory pressure, such as Flutter, Acapella, or AeroBika devices
E1399	Percussion cups
A4483	Heat moisture exchangers when used for mechanically ventilated clients who own their ventilator
A4481	Tracheostoma filters, such as Thermovent T, for clients with a tracheostomy who are not mechanically ventilated

Devices requiring prior authorizationHCPCSCovered

E0483	High-frequency chest wall oscillation system
E0482	Insufflation-exsufflation devices, such as Cough Assist or Vital Cough
E0480	Electrical percussors
E0481	Intrapulmonary percussion ventilation system
E0500	Intermittent positive-pressure breathing devices

HFCWO replacementHCPCSCovered

A7025

Vest replacement

Peak cough flow

ThresholdPeak cough flow below 270 lpm

PopulationAdolescent or adult

Clinical useSupports assessment of cough strength and deterioration requiring cough augmentation

Bronchiectasis productive cough

Required findingContinuous daily productive cough

Duration6 months

Condition

Authorization and Provider Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for rental or purchase of the following secretion and mucus-clearance devices:

HFCWO or CPT Vest system (E0483)
Insufflation-exsufflation or cough-assist devices (E0482)
Electrical percussors (E0480)
Intrapulmonary percussive ventilation (IPV) systems (E0481)
Intermittent positive-pressure breathing (IPPB) devices (E0500)

Note

Devices Exempt From Prior Authorization

The following devices or procedures do not require prior authorization when used under the stated conditions:

Incentive spirometers (A9284)
Mucus-clearance valved chambers, such as Flutter, Acapella, or AeroBika devices (S8185)

Rental and Purchase Rules by Device

Device / code	Rental terms	Purchase terms
Electrical percussor (E0480)	May be considered for rental when medical necessity and previous therapy history are documented. Continued out-of-network rental may be approved through the 10-month rent-to-purchase period when applicable network or prior-authorization conditions are met.	Considered purchased after 10 months of rental through the same provider. Purchase or further rental is not considered after that point.

Device / code	Rental terms	Purchase terms
Cough augmentation device (E0482)	Initial rental may be authorized for 3 months. Continued rental requires treating-physician documentation that the member is compliant and treatment is effective. Out-of-network continued rental may be approved for up to 90 days when applicable network or prior-authorization conditions are met.	No purchase provision is specified in the guideline.

Device / code	Rental terms	Purchase terms
High-frequency chest wall oscillation system (E0483)	Initial rental may be authorized for 3 months. An additional 3-month rental may be considered when purchase cannot yet be determined, if the required documentation and compliance evidence are submitted.	Considered purchased after 10 months of rental through the same provider. Purchase requires documentation of therapy results, effectiveness, tolerance, clinical improvement, hospitalization outcomes, compliance, and safety. Purchase is reimbursed once per lifetime.

Device / code	Rental terms	Purchase terms
Intrapulmonary percussive ventilation system (E0481)	Initial rental may be authorized for 3 months. The device is rental-only. Continued rental requires treating-physician documentation that the member is compliant and treatment is effective. Out-of-network continued rental may be approved for up to 90 days when applicable network or prior-authorization conditions are met.	Not applicable; the device is rental-only.

Device / code	Rental terms	Purchase terms
Intermittent positive-pressure breathing device (E0500)	The device is rented. Rental includes supplies such as humidification and tubing.	No purchase provision is specified in the guideline.

Replacement Rules

HFCWO vest replacement

HCPCS codeA7025

Replacement intervalNo fixed interval stated; replacement is condition-based

DocumentationDocument that the member can no longer wear the vest because of a change in condition, such as a change in height, weight, or skin abrasions

HFCWO system replacement

HCPCS codeE0483

Replacement limitOnce per lifetime

Rationale and timingThe system is considered purchased after 10 months of rental through the same provider; reimbursement is limited to once per lifetime because of the manufacturer's lifetime warranty

Required Documentation

Documentation Required

Submit the physician-completed authorization package

For rental or purchase, submit the applicable Texas Medicaid Prior Authorization Request for Secretion and Mucus Clearance Devices Initial Request or Renewal Request form, completed, signed, and dated by the treating physician, together with clinical medical-necessity documentation.

Initial Request form
Renewal Request form

Documentation Required

Document cough-augmentation medical necessity

For initial cough-augmentation rental, document the diagnosis and history, clinical evidence of cough deterioration to the level requiring augmentation, and medical reasons the parent, guardian, or caregiver cannot perform chest physiotherapy or why it was ineffective.

Include relevant illnesses, complications, medications, hospitalizations, and pulmonary-function results.
Include PFTs or peak cough flow when applicable.

Device Definitions

Cough augmentation device

DeviceCough augmentation device

Pressure sequencePositive pressure followed by negative pressure

PurposeStimulates a natural cough

High-frequency chest wall oscillation system

DeviceHigh-frequency chest wall oscillation system

DesignWearable vest applied to the chest wall

MechanismApplies vibrations at different frequencies to loosen mucus

Background

Secretion and mucous clearance devices support members who retain respiratory secretions, cannot clear secretions effectively, or develop mucus-plugging complications such as atelectasis. The guideline addresses mechanical cough augmentation, high-frequency chest wall oscillation, intrapulmonary percussion, electrical percussion, and intermittent positive-pressure breathing. For certain devices, documentation of failure or contraindication of simpler airway-clearance methods is required before authorization.

Not Covered and Excluded Scenarios

The following are not covered: IPV requested primarily for caregiver convenience; concurrent HFCWO and IPV when the specified pulmonologist-supported medical-necessity exception is not documented; and use of both systems without the required explanation of the purchased device’s failure and the medical necessity for the second device.

Policy Summary

PayerTexas Children's Health Plan

PolicySecretion and Mucous Clearance Devices Guideline

Policy CodePolicy 10577

Change TypeNo material change

Effective DateAug 31, 2023

Next Review DateN/A

Key ActionSubmit the required physician-completed prior-authorization form and clinical medical-necessity documentation.

SourceLink

On This Page

A weak, ineffective, or absent cough caused by chronic pulmonary disease or a neuromuscular disorder, resulting in respiratory complications from inability to clear mucus.

Documentation identifies other appropriate chest physiotherapy modes, based on age, ability, and skill, such as percussion and postural drainage therapy or a mechanical device, that were trialed by the member, parent, guardian, or caregiver and explains why the therapy was ineffective or contraindicated.

Documentation shows that any previous HFCWO use did not result in aspiration, exacerbation of a gastrointestinal or pulmonary condition, or exacerbation of seizure activity.

If purchase cannot be determined at the end of the initial three-month rental, an additional three-month rental may be considered when the above documentation and compliance with ordered therapy are submitted.

Frequency-of-use and compliance graphs for the three-month period show the prescribed frequency for each day and use of the system at least 50% of the prescribed time.≥ 50% of prescribed time

The treating physician states that prior HFCWO use did not result in aspiration, exacerbation of a gastrointestinal or pulmonary issue, or exacerbation of seizure activity.

The member's pulmonologist provides documentation describing the medical reasons HFCWO is contraindicated.

IPV is a rental-only device; after the initial three-month trial, continued rental requires treating-physician documentation of compliance with equipment use and treatment effectiveness.

Continued rental through an out-of-network provider may be approved for up to 90 days when the provider was in-network at initial rental or the member received the services under prior authorization from another Managed Care Organization or Fee-for-Service provider.

The requested device meets its applicable disease, prior-treatment, contraindication, documentation, rental, and effectiveness requirements under this guideline.

Applies separately to electrical percussors (E0480), cough augmentation devices (E0482), HFCWO systems (E0483), IPV systems (E0481), and IPPB devices (E0500).

Bronchiectasis confirmed by CT scan

Pulmonary infection exacerbations

FrequencyMore than 2 times per year

Clinical eventPulmonary infection exacerbations

Treatment requirementExacerbations requiring antibiotic therapy

Prior airway-clearance therapy

Minimum durationAt least 3 months when specified

HFCWOTrial percussion and postural drainage therapy before the request

IPVTrial appropriate chest physiotherapy or mechanical therapy before the request

HFCWO compliance

Minimum complianceAt least 50% of prescribed time

Measurement periodThree-month period

Required evidenceFrequency-of-use and compliance graphs showing prescribed frequency and actual use

Percussion cups (E1399)

Heat-moisture exchangers (A4483) only for mechanically ventilated clients who own their ventilator

Tracheostoma filters, such as Thermovent T (A4481), for clients with a tracheostomy who are not mechanically ventilated

Note

Submission Channels

Submit prior authorization requests to the Utilization Management Department during normal business hours through any of the following channels:

Online submission
Fax
Phone
Mail

Step Therapy

Electrical Percussor: Prior Therapy

Requests for an electrical percussor (E0480) must describe all previous courses of therapy and explain why they did not adequately assist with airway mucus clearance.

Document prior manual percussion and postural drainage (P&PD), valved-device therapy, or other relevant airway-clearance therapy.
Explain the member's response to each prior therapy and why it was ineffective or insufficient.

Unsupported block type: step_therapy teamp

Step Therapy

IPV Prerequisite Therapy

Before an IPV system (E0481) is considered, the member's parent, guardian, or caregiver must trial an appropriate chest-physiotherapy modality for at least three months.

Document percussion and postural drainage therapy or another appropriate mechanical modality.
Explain why the trialed therapy was ineffective or contraindicated.

Step Therapy

IPPB: Failed Alternatives

IPPB (E0500) requests must document an ineffective response to other treatment modalities, including cough-assist therapy, when applicable.

Document failure of other modalities and why they cannot meet the clinical objective.
Include the relevant inability to cooperate or inability to ventilate or cough effectively when applicable.

Documentation Required

Initial or Renewal Request Form

For an initial or renewal request for rental or purchase, submit the applicable Texas Medicaid Prior Authorization Request for Secretion and Mucus Clearance Devices form with clinical documentation supporting medical necessity.

Use the Initial Request form or Renewal Request form, as applicable.
The form must be completed, signed, and dated by the member's treating physician.

Documentation Required

General Medical-Necessity Evidence

Clinical documentation must clearly establish medical necessity for the selected secretion and mucus-clearance device.

Evidence of retained respiratory secretions
Difficulty clearing respiratory secretions
Atelectasis caused by mucus plugging

Documentation Required

Cough Augmentation Documentation

Cough-augmentation requests (E0482) require documentation completed, signed, and dated by the treating physician showing the qualifying condition and respiratory impairment.

Diagnosis and medical history, including recent illnesses, complications, medications, recent hospitalizations, and pulmonary-function results when applicable
Clinical evidence of deterioration requiring cough augmentation, such as PFTs or peak cough flow below 270 L/min in an adolescent or adult
Medical reasons the parent, guardian, or caregiver cannot perform chest physiotherapy, or why it was previously ineffective
For continued rental after the initial three-month trial, document equipment compliance and treatment effectiveness

Documentation Required

HFCWO Supporting Documentation

HFCWO requests (E0483) must document a qualifying condition, the response or contraindication to prior therapy, and the member's airway-clearance therapy history.

Qualifying disease, such as CT-confirmed bronchiectasis with the required productive cough or exacerbation history, cystic fibrosis or chronic suppurative endobronchitis, chronic neuromuscular disease, or weak, ineffective, or absent cough caused by chronic pulmonary or neuromuscular disease
Results of at least three months of appropriate prior chest physiotherapy and why it was ineffective or contraindicated
Any prior HFCWO use and documentation that it did not cause aspiration, gastrointestinal or pulmonary exacerbation, or seizure exacerbation
For an additional rental period, document compliance with ordered therapy

Documentation Required

HFCWO Purchase Documentation

A purchase request after the initial three-month HFCWO rental must document that the system was effective and tolerated and include the treating physician's assessment of respiratory outcomes.

Results of HFCWO therapy and evidence of effectiveness and vest tolerance
Treating physician's assessment, diagnosis, and respiratory history
Respiratory complications and decreases in those complications
Recent respiratory hospitalizations, shorter lengths of stay, and decreased hospitalizations
Three-month frequency-of-use and compliance graphs showing use at least 50% of prescribed time
Physician statement that HFCWO did not cause aspiration, gastrointestinal or pulmonary exacerbation, or seizure exacerbation

Documentation Required

IPV Supporting Documentation

IPV requests (E0481) require documentation that HFCWO is contraindicated, the member has a qualifying disease and respiratory impairment, and appropriate prior therapy was unsuccessful or contraindicated.

Pulmonologist's description of the medical reasons HFCWO is contraindicated
Chronic pulmonary disease or neuromuscular disorder affecting respiratory musculature with weak, ineffective, or absent cough
Qualifying bronchiectasis or chronic respiratory illness with inadequate secretion clearance and resulting complications
At least three months of caregiver-trialed, appropriate chest physiotherapy and the reason it was ineffective or contraindicated

Documentation Required

IPPB Supporting Documentation

IPPB (E0500) requires documentation that other modalities were ineffective, the device is prescribed consistently with AARC recommendations, and there is medical necessity to improve lung expansion or achieve aerosol delivery.

Document ineffective response to other modalities, including cough-assist therapy when applicable
Document clinically significant atelectasis, inability to clear secretions, or inability to ventilate or cough effectively
For aerosol delivery, document unsuccessful alternative delivery methods and applicable ventilatory muscle weakness or severe hyperinflation
Include the prescribing physician's clinical rationale and applicable AARC-based requirements

Step Therapy

HFCWO Is Not First-Line

HFCWO is not considered first-line therapy. The member must complete the required trial of other percussion and postural-drainage therapy before an HFCWO request is considered, subject to the stated exception.

Minimum prior-therapy period: three months
Exception may be considered for cystic fibrosis and bronchiectasis with chronic mucopurulent bronchitis

Denial Risk

Caregiver Convenience

An IPV request is not a benefit when made primarily for caregiver convenience.

The request must be supported by the member's clinical needs and medical necessity.

Denial Risk

Duplicate Airway-Clearance Systems

A member generally may not receive both an HFCWO system and an IPV system because the devices have similar actions on mucus clearance.

An exception may be considered with a detailed medical-necessity letter from the treating pulmonologist explaining why a purchased device failed and why the other device is medically necessary.
For severe neuromuscular disease with ineffective cough and recurrent pneumonia, both cough assist and HFCWO or IPV may be requested with the required pulmonologist letter.

Denial Risk

IPPB Is Not Clinically Preferred

IPPB is not the therapy of first choice for aerosol delivery or lung hyperinflation when other therapies can reliably meet the member's clinical objectives.

Use IPPB only when alternatives are unsuccessful or cannot meet the prescribed clinical objective.
Rental includes supplies such as humidification and tubing.

Note

Criteria Not Met

Requests that do not meet the guideline criteria will be reviewed case by case by a Texas Children's Health Plan Medical Director or Physician Reviewer.

Prior authorization is based on medical necessity and is not a guarantee of benefits or eligibility.
Approved authorization applies only to the medical necessity of the treatment or service; benefit limitations and exclusions still apply.

Documentation Required

Document HFCWO qualification and safety

For HFCWO, document a qualifying condition, failure or contraindication of prior therapy, prior appropriate therapy trials, and that previous HFCWO use did not cause aspiration or gastrointestinal, pulmonary, or seizure exacerbation.

Document why the prior therapy was ineffective or contraindicated.
Include the required safety history.

Documentation Required

Document HFCWO effectiveness before purchase

Before HFCWO purchase, submit therapy results, effectiveness and tolerance, vest tolerance, physician assessment, respiratory and hospitalization outcomes, use and compliance graphs, and the treating physician’s safety statement.

Compliance graphs must show use at least 50% of prescribed time during the three-month period.
Document evidence of decreased respiratory complications and hospitalizations.

Documentation Required

Document IPV-specific medical necessity

For IPV, document the qualifying pulmonary or neuromuscular disease, respiratory impairment and complications, at least three months of prior appropriate therapy with its outcome or contraindication, and the HFCWO contraindication documented by the member’s pulmonologist.

Include the pulmonologist’s medical reasons HFCWO is contraindicated.
Document inability to adequately clear secretions or other qualifying respiratory complications.

Documentation Required

Support rental recertification

For continued rental after the initial three-month trial, submit treating-physician documentation that the member is compliant with equipment use and that treatment is effective.

Applies to continued cough-augmentation rental.
Applies to continued IPV rental.
Certain out-of-network continued rentals may be approved for up to 90 days when the stated authorization conditions apply.

Intrapulmonary percussive ventilation system

DeviceIntrapulmonary percussive ventilation system

Delivery methodShort bursts of air through a mouthpiece or mask

PurposeLoosens mucus

Intermittent positive-pressure breathing

DeviceIntermittent positive-pressure breathing device

Breathing supportProvides short-term or intermittent positive-pressure breaths

UsesAugments lung expansion, delivers aerosol medication, or assists ventilation

Electrical percussor

DeviceElectrical percussor

TypeElectrical device

PurposeUsed for chest percussion or vibration

Percussion cup

DevicePercussion cup

TypeManual chest-physical-therapy cup

TechniqueUsed for pounding and postural drainage