ModifiedUnitedHealthcarePolicy CS054KS.03

Airway Clearance Devices (for Kansas Only)

Medical policy governing coverage and clinical criteria for airway clearance devices (e.g., high-frequency chest wall oscillation, intrapulmonary percussive ventilation, combination OLE devices) for UnitedHealthcare members in Kansas.

Policy Summary

PayerUnitedHealthcare

PolicyAirway Clearance Devices (for Kansas Only)

Policy CodePolicy CS054KS.03

Change TypeAdded not medically necessary designationcoding updatesdocumentation guidance

Effective DateApr 1, 2026

Next Review Date

Key ActionFollow Kansas DME Fee‑for‑Service manual and InterQual criteria for prior authorization and submit medical records that support medical necessity upon request.

SourceLink

POLICY UPDATE CHANGES

Added language to indicate combination continuous positive expiratory pressure, continuous high-frequency oscillation, and nebulized medication therapy devices for oscillation and lung expansion are considered unproven and not medically necessary.

Added medical records documentation guidance used for reviews (requirements for documentation to support medical necessity).

Added applicable HCPCS codes A7021 and E0469 and multiple ICD-10 diagnosis codes.

Added Clinical Evidence section and updated Description of Services and References.

Kansas-onlystate application

2HCPCS codes added

~40+ICD-10 codes added

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Coverage and Medical Necessity Criteria

Coverage references and application

Policy coverage summary and referenced criteria sources

Primary coverage rules: This policy applies only to Kansas. For medical necessity clinical coverage criteria for a high frequency chest wall oscillation system, refer to the Kansas Medical Assistance Program, Durable Medical Equipment Fee-for-Service Provider Manual; for an intrapulmonary percussive ventilation system, refer to InterQual® CP: Durable Medical Equipment, Airway or Secretion Clearance Devices.

Providers must use the referenced manuals/criteria to determine specific authorization requirements.

Combination OLE devices — Not medically necessary

Not medically necessary when the following ALL apply

Combination OLE devices: Combination continuous positive expiratory pressure, continuous high-frequency oscillation, and nebulized medication therapy devices for oscillation and lung expansion are considered unproven and not medically necessary due to insufficient quality evidence or inconsistency of findings.

Explicit not medically necessary stance in policy.

Combination OLE devices — Not medically necessary — Policy position for combination oscillation and lung expansion devices

Policy position for combination oscillation and lung expansion devices

Not medically necessary determination: Combination continuous positive expiratory pressure, continuous high-frequency oscillation, and nebulized medication therapy devices for oscillation and lung expansion are considered unproven and not medically necessary.

Added in 04/01/2026 policy revision; well-designed, adequately powered prospective controlled trials are needed to further describe safety and efficacy.

High-frequency chest wall compression devices — Indication

Device description and indication

Indication: High-frequency chest wall compression devices are designed to promote airway clearance and improve bronchial drainage and are indicated when external chest manipulation is the physician's treatment of choice to enhance mucus transport.

Descriptive/indication statement; consult referenced coverage criteria for authorization guidance.

Combination continuous positive expiratory pressure (PEP), continuous high-frequency oscillation, and nebulized medication therapy devices intended for oscillation and lung expansion (OLE) are designated in this policy as unproven and not medically necessary. This determination is based on the policy statement that such combination devices lack sufficient quality evidence and consistent findings to support coverage for the intended OLE purpose.

Providers should note that requests for devices described as combination continuous PEP/continuous high-frequency oscillation/nebulized medication therapy for oscillation and lung expansion are excluded from coverage under the policy and are subject to denial on the basis that the technology is considered not medically necessary.

The policy was revised effective 04/01/2026 to explicitly add language that combination continuous PEP, continuous high-frequency oscillation, and nebulized medication therapy devices for oscillation and lung expansion are unproven and not medically necessary. This addition is reflected in the Summary of Changes and serves as the formal policy position.

Operational notes added with the revision reiterate that medical records documentation may be requested to assess whether a member meets clinical criteria for coverage, but that supplying documentation does not guarantee approval when the device is listed as not medically necessary per the policy.

Alternate phrasing in the policy describes these products as "combination continuous PEP, continuous high-frequency oscillation, and nebulized medication therapy devices for oscillation and lung expansion" and restates that, due to insufficient quality of evidence or inconsistent findings, such combination devices are considered unproven and not medically necessary.

This language is intended to cover devices that integrate multiple modalities (positive expiratory pressure, oscillatory chest wall or intrapulmonary oscillation, and nebulization) into a single system for the goal of oscillation and lung expansion.

Additional policy text clarifies that combination CPAP/continuous high-frequency oscillation and nebulized medication therapy devices intended for oscillation and lung expansion are similarly categorized as unproven and not medically necessary and therefore excluded from coverage.

Providers should treat these statements as the policy's exclusion rationale when submitting requests or prior authorization documentation for combination OLE devices.

Applicable Codes and Evidence Summary

Applicable HCPCSHCPCS

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.
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.
E0469	Lung expansion airway clearance, continuous high frequency oscillation, and nebulization device

Applicable ICD-10 diagnosesICD-10

A80.0	Acute paralytic poliomyelitis, vaccine-associated.
A80.1	Acute paralytic poliomyelitis, wild virus, imported.
A80.2	Acute paralytic poliomyelitis, wild virus, indigenous.
A80.30	Acute paralytic poliomyelitis, unspecified.
A80.39	Other acute paralytic poliomyelitis.
A80.4	Acute nonparalytic poliomyelitis.
A80.9	Acute poliomyelitis, unspecified.
B91	Sequelae of poliomyelitis.
E74.02	Pompe disease.
E74.4	Disorders of pyruvate metabolism and gluconeogenesis.

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Applicable HCPCS Codes (added)HCPCS

A7021	HCPCS code added (as listed in policy history)
E0469	HCPCS code added (as listed in policy history)

Applicable ICD-10 Codes (added)ICD-10

A80.0	ICD-10 code added
A80.1	ICD-10 code added
A80.2	ICD-10 code added
A80.30	ICD-10 code added
A80.39	ICD-10 code added
A80.4	ICD-10 code added
A80.9	ICD-10 code added
B91	ICD-10 code added
E74.02	ICD-10 code added
E74.4	ICD-10 code added

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Evidence certainty — Summary

Summary findingMost comparative outcomes in cited systematic reviews were rated as low or very low certainty (GRADE or equivalent), with many studies small, heterogeneous, and at risk of bias.

Evidence base sizeSystematic reviews included dozens of studies (examples: Main & Rand: 21 studies, Morrison & Milroy: 39 studies) but individual studies were generally small (median ~23 participants) and varied in design.

Common limitationsHeterogeneous interventions, variable durations, limited analyzable data, and inability to blind participants/clinicians contributed to low certainty ratings.

Evidence requirement — Research needs

Needed study designWell-designed, adequately powered, prospective, controlled clinical trials are needed to better describe safety and clinical efficacy of combination OLE therapy.

Prior Authorization, Documentation, and Denial Risk

Prior Authorization

Prior Authorization Required

Prior authorization is required for devices and supplies described in this policy. Refer to applicable Kansas DME prior authorization requirements and InterQual criteria for medical necessity determinations.

Applicable HCPCS: A7021, A7025, A7026, E0469, E0481, E0483

Denial Risk

Denial Risk for Combination Devices

Requests for combination devices that provide CPAP/continuous high-frequency oscillation and nebulized medication (combination OLE devices) are considered unproven and are not medically necessary; such requests are likely to be denied.

Background and Clinical Context

Airway clearance devices commonly referenced in this policy include high-frequency chest wall oscillation systems and intrapulmonary percussive ventilation; these devices are used to assist secretion clearance and promote lung expansion in conditions where airway clearance is impaired (for example, cystic fibrosis, neuromuscular disease, or bronchiectasis).

The policy cites systematic reviews and prospective studies assessing outcomes such as lung function, exacerbation frequency, and healthcare utilization but notes that, for many comparative outcomes, the evidence certainty is low or very low. As a result, the policy takes a cautious stance and classifies certain combination devices (OLE) as unproven and not medically necessary.

Definitions

OLE — Definition

TermOLE (Oscillation and Lung Expansion)

DefinitionCombination continuous positive expiratory pressure, continuous high-frequency oscillation, and nebulized medication therapy devices intended for oscillation and lung expansion.

Policy implicationThese combined devices are considered unproven and not medically necessary due to insufficient quality or consistency of evidence.

High-frequency chest wall compression devices — Definition and intended use

Device classHigh-frequency chest wall compression devices (HFCWC)

DefinitionDevices designed to promote airway clearance and improve bronchial drainage via external chest manipulation delivering high-frequency oscillatory compression.