Notification



Notification Issue Date:



Medical Policy Bulletin


Title:High-Frequency Chest Wall Oscillation Devices

Policy #:05.00.14j

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.


MEDICALLY NECESSARY

A 4- to 6-week rental trial of a high-frequency chest wall oscillation device (HFCWO) is considered medically necessary and, therefore, covered for the treatment of individuals who have a documented history that confirms a failure of standard treatments (eg, manual chest percussion, postural drainage) to adequately mobilize retained bronchial secretions, and have one of the following diagnoses:
  • Cystic fibrosis
  • Bronchiectasis confirmed by computed tomography (CT) scan and documentation of any of the following:
    • Daily productive cough for at least six continuous months
    • Frequent (ie, more than two per year) exacerbations of respiratory infection requiring antibiotic therapy
  • Late effects of acute poliomyelitis
  • Acid maltase deficiency
  • Anterior horn cell diseases
  • Multiple sclerosis
  • Quadriplegia
  • Hereditary muscular dystrophy
  • Myotonic disorders
  • Other myopathies (eg, toxic myopathy, myopathy in endocrine diseases, symptomatic inflammatory myopathy)
  • Paralysis of the diaphragm

Continued coverage of the HFCWO device after the trial is considered medically necessary and, therefore, covered when the effectiveness of the device has been demonstrated by both of the following:
  • Documentation that the device has been used daily or as prescribed
  • Documentation of increased expectoration of mucus

If the trial of the device is successful and the individual wishes to continue using the device, continued authorization for the device must be obtained. The ordering professional provider must provide a letter of medical necessity to the Company stating compliance with the above requirements.

NOT MEDICALLY NECESSARY

HFCWO devices for any diagnosis other than those mentioned above are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support the use of this device for the treatment of any other diagnosis.

The use of both an HFCWO device and a mechanical in-exsufflation device that assists with coughing by gradually applying a positive pressure to the airway and then rapidly shifting to a negative pressure is considered not medically necessary and, therefore, not covered.

ABSOLUTE CONTRAINDICATIONS
A HFCWO device is considered not medically necessary and, therefore, not covered for individuals with any of the following absolute contraindications:
  • Head and neck injury until stabilized
  • Active hemorrhage with hemodynamic instability

FACE-TO-FACE REQUIREMENTS

As a condition for payment, a professional provider must have a face-to-face examination with the individual for whom the item is ordered that meets all of the following requirements:
  • The treating professional provider must have an in-person examination with the individual within the six (6) months prior to the date of the written order prior to delivery.
  • This examination must document that the individual was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.

A new face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required:
  • For all claims for purchases or initial rentals
  • When there is a change in the prescription for the accessory, supply, drug, etc.
  • If periodic prescription renewal required per medical policy
  • When an item is replaced
  • When there is a change in the supplier
  • When required by state law

In this policy the specified item is: E0483: High Frequency Chest Wall Oscillation Air-Pulse Generator System (Includes Hoses and Vest), Each.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include, but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

Documentation of a face-to-face encounter, between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual’s clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.

If required documentation is not available on file to support a claim at the time of an audit or record request, the DME supplier may be required to reimburse the Company for overpayments.
Guidelines

HFCWO DEVICE VESTS

Manufacturers make HFCWO device vests to fit individuals based on chest measurements. Currently, the smallest vest accommodates a chest circumference of 16 inches; the largest vest accommodates a chest circumference of 68 inches.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, HFCWO devices are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met. However, when an HFCWO device is used in an individual who has either of the absolute contraindications listed in this policy, it is considered not medically necessary and, therefore, not covered.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous devices approved by the FDA for the mobilization of bronchial secretions.

Description

A high-frequency chest wall oscillation (HFCWO) device is designed to enhance the mobilization of bronchial secretions. The device is an inflatable vest that is connected by two tubes to a small air-pulse generator. Oscillating positive air pressure causes the vest to inflate and deflate up to 25 times a minute, creating a vibratory motion that aids in the mobilization of secretions. The action of the device creates mini-coughs that dislodge mucus from the bronchial walls, thus increasing mobilization of the mucus toward the central airways. The oscillating action also thins the secretions and makes them easier to remove by coughing or suctioning. A typical treatment with the device lasts up to 20 minutes.

HFCWO devices can be used for individuals who have respiratory disorders such as cystic fibrosis (CF) or bronchiectasis that require chest physiotherapy, manual chest percussion, postural drainage, and device-assisted coughing to help them clear their lungs. CF is a genetic disorder in which thick mucus blocks the small tubules of the lungs. Bronchiectasis is a chronic dilation of the bronchi or bronchioles that is associated with heavy sputum production and occurs as a consequence of inflammatory disease or obstruction. When the bronchial tubes become enlarged and distended, they form pockets that can create opportunities for infection. Once the bronchial tubes are damaged or obstructed, the lung's complex cleaning system is compromised. To deter respiratory infection and minimize obstruction, the bronchial secretions must be mobilized toward the central airways. In individuals with CF or bronchiectasis, an HFCWO device can aid in the movement and expectoration of these secretions.

HFCWO devices can also be used for individuals who have neuromuscular diseases, such as multiple sclerosis, hereditary muscular dystrophy, and quadriplegia, that require chest physiotherapy, manual chest percussion, postural drainage, and device-assisted coughing to help them clear their lungs. Neuromuscular disease often results in weakness in diaphragmatic, chest wall, and abdominal wall muscles that are associated with insufficient cough strength. By virtue of an inability to cough and effectively remove accumulated secretions, individuals with neuromuscular disease have an increased risk of pneumonia and other lung infections. In individuals with specified neuromuscular disease, an HFCWO device can aid in the movement and expectoration of these secretions.
References


American Association for Respiratory Care (AARC). AARC Clinical Practice Guideline. Effectiveness of nonpharmacologic airway clearance therapies in hospitalized patients. Respir Care. 2013;58(12):2187-2193. Also available on the Respiratory CareWeb site at: https://www.ncbi.nlm.nih.gov/pubmed/24222709. Accessed April 1, 2019.

American Association for Respiratory Care (AARC). Foreword. New horizons in respiratory care: Airway clearance techniques. Respir Care. 2002;47(7):759. Also available on the Respiratory Care Web site at: http://www.rcjournal.com/contents/07.02/07.02.0759.cfm. Accessed April 1, 2019.

App EM, Kieselmann R, Reinhardt D, et al. Sputum rheology changes in cystic fibrosis lung disease following two different types of physiotherapy: flutter vs autogenic drainage. Chest. 1998;114(1):171-177.

Arens R, Gozal D, Omlin KJ, et al. Comparison of high frequency chest compression and conventional chest physiotherapy in hospitalized patients with cystic fibrosis. Am J Respir Crit Care Med. 1994;150(4):1154-1157.

Braggion C, Cappelletti LM, Cornacchia M, et al. Short-term effects of three chest physiotherapy regimens in patients hospitalized for pulmonary exacerbations of cystic fibrosis: a cross-over randomized study. Pediatr Pulmonol. 1995;19(1):16-22.

Canadian Lung Association. Bronchiectasis. [Canadian Lung Association Web site]. 2015. Available at: https://www.lung.ca/lung-health/lung-disease/bronchiectasis. Accessed April 1, 2019.

Centers for Medicare & Medicaid Services (CMS). Face-to-Face Encounter Requirement for Certain Durable Medical Equipment. [CMS Web site]. 11/16/2012 (Revised 09/09/2015). Available at:
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment.html. Accessed April 1, 2019.

Eaton T, Young P, Zeng I, Kolbe J. A randomized evaluation of the acute efficacy, acceptability and tolerability of flutter and active cycle of breathing with and without postural drainage in non-cystic fibrosis bronchiectasis. Chron Respir Dis. 2007;4(1):23-30.

Electromed, Inc. SmartVest® Airway Clearance System. [Electromed Web site]. 2014. Available at: http://www.smartvest.com/smartvest-system/. Accessed April 1, 2019.

Elkins MR, Jones A, van der Schans C. Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis. Cochrane Database Syst Rev. 2006;(2):CD003147.

Flume PA, Robinson KA, O'Sullivan BP, et al. Cystic Fibrosis Pulmonary Guidelines: Airway clearance therapies. Respir Care. 2009;54(4):522-537.

Goktalay T, Akdemir SE, Alpaydin AO, et al. Does high-frequency chest wall oscillation therapy have any impact on the infective exacerbations of chronic obstructive pulmonary disease? A randomized controlled single-blind study. Clin Rehabil. 2013; 27(8):710-8.

Hess DR. The evidence for secretion clearance techniques. Respir Care.
2001;46(11):1276-1293.

Hill-Rom Services. The Vest™ Airway Clearance System. [The Vest Web site]. 2013 Available at: http://www.thevest.com/. Accessed October 26, 2017.

Homnick DN, White F, de Castro C. Comparison of effects of an intrapulmonary percussive ventilator to standard aerosol and chest physiotherapy in treatment of cystic fibrosis. Pediatr Pulmonol. 1995;20(1):50-55.

Kachel DL, Davey CS, Kennedy TC, et al. Utility of a high-frequency chest wall oscillation (HFCWO) trial period to assess treatment satisfaction, adherence and benefit in patients with COPD. [Chest Web site]. 11/02/05. Available at: http://journal.publications.chestnet.org/article.aspx?articleid=1213008. Accessed April 1, 2019.

Kempainen RR, Williams CB, Hazelwood A, et al. Comparison of high-frequency chest wall oscillation with differing waveforms for airway clearance in cystic fibrosis. Chest. 2007;132(4):1227-1232.

Kluft J, Beker L, Castagnino M, et al. A comparison of bronchial drainage treatments in cystic fibrosis. Pediatr Pulmonol. 1996;22(4):271-274.

Langenderfer B. Alternatives to percussion and postural drainage. A review of mucus clearance therapies: percussion and postural drainage, autogenic drainage, positive expiratory pressure, flutter valve, intrapulmonary percussive ventilation, and high-frequency chest compression with the ThAIRapy Vest. J Cardiopulm Rehabil. 1998;18(4):283-289.

Lee AL, Burge A, Holland AE. Airway clearance techniques for bronchiectasis. Cochrane Database Syst Rev. 2013; 5:CD008351.

Main E, Prasad A, van der Schans C. Conventional chest physiotherapy compared to other airway clearance techniques for cystic fibrosis. The Cochrane Database of Systematic Reviews. 2009;1:CD002011, DOI:10.1002/14651858. [The Cochrane Library Web site]. 04/15/09. Available at: http://www.thecochranelibrary.com [via subscription only]. Accessed April 1, 2019.

Marks JH. Airway clearance devices in cystic fibrosis. Paediatr Respir Rev. 2007;8(1):17-23.

Marshall BC, Samuelson WM. Basic therapies in cystic fibrosis. Does standard therapy work? Clin Chest Med.1998;19(3):487-504.

McCool FD, Rosen MJ. Nonpharmacologic airway clearance therapies: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 suppl):250S-259S.

McIlwaine MP, Alarie N, Davidson GF, et al. Long-term multicentre randomised controlled study of high frequency chest wall oscillation versus positive expiratory pressure mask in cystic fibrosis. Thorax. 2013;68(8):746-751.

McIlwaine PM, Wong LT, Peacock D, Davidson AG. Long-term comparative trial of positive expiratory pressure versus oscillating positive expiratory pressure (flutter) physiotherapy in the treatment of cystic fibrosis. J Pediatr. 2001;138(6):845-850.

Murray MP, Pentland JL, Hill AT. A randomised crossover trial of chest physiotherapy in non-cystic fibrosis bronchiectasis. Eur Respir J. 2009;34(5):1086-1092.

National Institute of Neurologic Disorders and Stroke (NINDS). Inflammatory myopathies fact sheet. National Institutes of Health (NIH) Publication No. 11-5321. [NINDS Web site]. 08/26/11. Available at: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Inflammatory-Myopathies-Fact-Sheet. Accessed April 1, 2019.

Newhouse PA, White F, Marks JH, Homnick DM. The intrapulmonary percussive ventilator and flutter device compared to standard chest physiotherapy in patients with cystic fibrosis. Clin Pediatr (Phila). 1998;37(7):427-432.

Nicolini A, Cardini F, Landucci N, et al. Effectiveness of treatment with high-frequency chest wall oscillation in patients with bronchiectasis. BMC Pulm Med. 2013;13:21.

Nicolini A, Merliak F, Barlascini C. Use of positive expiratory pressure during six minute walk test: results in patients with moderate to severe chronic obstructive pulmonary disease. Multidiscip Respir Med. 2013 Mar 14;8(1):19.

Noridian Healthcare Solutions. Local Coverage Determination (LCD and Policy Article). L33785 & A52494. High frequency chest wall oscillation devices. Original 10/01/2015, Revised 01/01/2019. Available at: https://med.noridianmedicare.com/documents/2230703/7218263/High+Frequency+Chest+Wall+Oscillation+Devices/2c8213bc-6773-4dcf-9fa5-80557b80b888. Accessed April 1, 2019.

Noridian Healthcare Solutions. Local Coverage Article.A55426. Standard Documentation Requirements for All Claims Submitted to DME MACs . Original 01/01/2017, Revised 01/01/2019. Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=55426. Accessed April 1, 2019.

Oermann CM, Sockrider MM, Giles D, et al. Comparison of high-frequency chest wall oscillation and oscillating positive expiratory pressure in the home management of cystic fibrosis: a pilot study. Pediatr Pulmonol. 2001;32(5):372-377.

Patterson JE, Bradley JM, Hewitt O, et al. Airway clearance in bronchiectasis: a randomized crossover trial of active cycle of breathing techniques versus Acapalla. Respiration.
2005;72(3):239-242.

Patterson JE, Hewitt O, Kent L, et al. Acapella versus 'usual airway clearance' during acute exacerbation in bronchiectasis: a randomized crossover trial. Chron Respir Dis. 2007;4(2):67-74.

Phillips GE, Pike SE, Jaffé A, Bush A. Comparison of active cycle of breathing and high-frequency oscillation jacket in children with cystic fibrosis. Pediatr Pulmonol. 2004;37(1):71-75.

Siafakas NM, Alexopoulou C, Bouros D. Respiratory muscle function in endocrine diseases. Monaldi Arch Chest Dis. 1999;54(2):154-9.

Scherer TA, Barandun J, Martinez E, et al. Effect of high-frequency oral airway and chest wall oscillation and conventional chest physical therapy on expectoration in patients with stable cystic fibrosis. Chest. 1998;113(4):1019-1027.

Thompson CS, Harrison S, Ashley J, et al. Randomised crossover study of the Flutter device and the active cycle of breathing technique in non-cystic fibrosis bronchiectasis. Thorax.
2002;57(5):446-448.


US Food and Drug Administration (FDA). Center for Devices and Radiological Health. ABI Vest™ Airway Clearance System. Summary of safety and effectiveness. [FDA Web site]. 01/21/2000. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf/k993629.pdf. Accessed April 1, 2019.

Varekojis SM, Douce FH, Flucke RL, et al. A comparison of the therapeutic effectiveness of and preference for postural drainage and percussion, intrapulmonary percussive ventilation, and high-frequency chest wall compression in hospitalized cystic fibrosis patients. Respir Care. 2003;48(1):24-28.

Volsko TA, DiFiore J, Chatburn RL. Performance comparison of two oscillating positive expiratory pressure devices: Acapella versus Flutter. Respir Care. 2003;48(2):124-130.

Warnock L, Gates A, van der Schans CP. Chest physiotherapy compared to no chest physiotherapy for cystic fibrosis. Cochrane Database of Systematic Reviews. 2013; Issue 9. Art. No.: CD001401. DOI: 10.1002/14651858.CD001401.pub2.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

THIS IS NOT AN ALL- INCLUSIVE LIST

A15.0 Tuberculosis of lung

B91 Sequelae of poliomyelitis

D81.810 Biotinidase deficiency

D84.1 Defects in the complement system

E84.0 Cystic fibrosis with pulmonary manifestations

E84.9 Cystic fibrosis, unspecified

G12.0 Infantile spinal muscular atrophy, type I [Werdnig-Hoffman]

G12.1 Other inherited spinal muscular atrophy

G12.20 Motor neuron disease, unspecified

G12.21 Amyotrophic lateral sclerosis

G12.22 Progressive bulbar palsy

G12.23 Primary lateral sclerosis

G12.24 Familial motor neuron disease

G12.25 Progressive spinal muscle atrophy

G12.29 Other motor neuron disease

G12.8 Other spinal muscular atrophies and related syndromes

G12.9 Spinal muscular atrophy, unspecified

G14 Postpolio syndrome

G35 Multiple sclerosis

G71.00 Muscular dystrophy, unspecified

G71.01 Duchenne or Becker muscular dystrophy

G71.02 Facioscapulohumeral muscular dystrophy

G71.09 Other specified muscular dystrophies

G71.11 Myotonic muscular dystrophy

G71.12 Myotonia congenita

G71.13 Myotonic chondrodystrophy

G71.14 Drug induced myotonia

G71.19 Other specified myotonic disorders

G71.2 Congenital myopathies

G71.3 Mitochondrial myopathy, not elsewhere classified

G71.8 Other primary disorders of muscles

G72.0 Drug-induced myopathy

G72.1 Alcoholic myopathy

G72.2 Myopathy due to other toxic agents

G72.49 Other inflammatory and immune myopathies, not elsewhere classified

G72.89 Other specified myopathies

G73.7 Myopathy in diseases classified elsewhere

G80.0 Spastic quadriplegic cerebral palsy

G82.50 Quadriplegia, unspecified

G82.51 Quadriplegia, C1-C4 complete

G82.52 Quadriplegia, C1-C4 incomplete

G82.53 Quadriplegia, C5-C7 complete

G82.54 Quadriplegia, C5-C7 incomplete

J47.0 Bronchiectasis with acute lower respiratory infection

J47.1 Bronchiectasis with (acute) exacerbation

J47.9 Bronchiectasis, uncomplicated

J98.6 Disorders of diaphragm

M05.40 Rheumatoid myopathy with rheumatoid arthritis of unspecified site

M05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sites

M33.02 Juvenile dermatomyositis with myopathy

M33.12 Other dermatomyositis with myopathy

M33.22 Polymyositis with myopathy

M33.92 Dermatopolymyositis, unspecified with myopathy

M34.82 Systemic sclerosis with myopathy

M35.03 Sicca syndrome with myopathy

Q33.4 Congenital bronchiectasis




HCPCS Level II Code Number(s)



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

E0483 High frequency chest wall oscillation system, includes all accessories and supplies, each



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

05.00.14j
05/22/2019The policy has been reviewed and reissued to communicate the Company’s continuing position on High-Frequency Chest Wall Oscillation Devices.
01/01/2019This policy has been identified for the HCPCS code update effective 01/01/2019.

The following HCPCS code narrative has been revised in this policy:

E0483 High frequency chest wall oscillation system, includes all accessories and supplies, each

05.00.14i
10/01/2018This policy has been identified for the ICD-10 CM code update, effective 10/01/2018.

The following ICD-10 code has been deleted:
G71.0 Muscular dystrophy

The following ICD-10 codes have been added:
G71.00 Muscular dystrophy, unspecified
G71.01 Duchenne or Becker muscular dystrophy
G71.02 Facioscapulohumeral muscular dystrophy
G71.09 Other specified muscular dystrophies

05.00.14h
08/15/2018This policy has been reissued in accordance with the Company's annual review process.
11/22/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on High-Frequency Chest Wall Oscillation Devices.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2019
Version Issued Date: 01/02/2019
Version Reissued Date: 05/22/2019

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