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High-Frequency Chest Wall Oscillation Devices
05.00.14s

Policy

MEDICALLY NECESSARY

A high-frequency chest wall oscillation (HFCWO) device is considered medically necessary and, therefore, covered for the treatment of individuals who have a documented history that confirms a failure of standard treatments (e.g., manual chest percussion, postural drainage) to adequately mobilize retained bronchial secretions and also 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 6 continuous months
    • Frequent (i.e., more than two per year) exacerbations of respiratory infection requiring antibiotic therapy

         Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed diagnosis of bronchiectasis do not meet this criterion.                         

  • Post-polio syndrome
  • Acid maltase deficiency
  • Anterior horn cell diseases
  • Multiple sclerosis
  • Quadriplegia
  • Hereditary muscular dystrophy
  • Myotonic disorders
  • Other myopathies
  • Paralysis of the diaphragm​
​ 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.

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.

STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written 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 standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY REQUIREMENTS
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 durable medical equipment (DME) supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES (WHEN APPLICABLE)
The 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 7 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 5 days before the individual would exhaust their on-hand supply.

For specified DME items, 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

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, high-frequency chest wall oscillation ​(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. 

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 Misspelled Wordsm​all 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.

American Association for Respiratory Care (AARC). Foreword. New horizons in respiratory care: Airway clearance techniques. Respir Care. 2002;47(7):759.

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.

Centers for Medicare & Medicaid Services (CMS). Required Face-to-Face Encounter and Written Order Prior to Delivery List. [CMS Web site]. 11/16/2012 (Revised 08/12/2024). Available at: https://www.cms.gov/files/document/required-face-face-encounter-and-written-order-prior-delivery-list.pdf. Accessed August 15, 2025.


Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; End-stage renal disease prospective payment system, payment for renal dialysis services furnished to individuals with acute kidney injury, end-stage renal disease quality incentive program, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee schedule amounts, DMEPOS competitive bidding program (CBP) amendments, standard elements for a DMEPOS order, and master list of DMEPOS items potentially subject to a face-to-face encounter and written order prior to delivery and/or prior authorization requirements for calendar year (CY) 2020; Final Rule. [Federal Register Web site]. 11/08/2019. Available at: https://www.federalregister.gov/documents/2019/11/08/2019-24063/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis. Accessed August 15, 2025.

Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; Updates to Face-to-Face Encounter and Written Order Prior to Delivery List. [Federal Register Web Site]. 01/17/2023. Available
at: https://www.federalregister.gov/documents/2023/01/17/2023-00718/medicare-program-updates-to-face-to-face-encounter-and-written-order-prior-to-delivery-list. Accessed August 15, 2025.

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]. 2022. Available at: https://smartvest.com/wp-content/uploads/2017/12/SmartVest-SV2100-Instruction-Manual.pdf. Accessed August 15, 2025.

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):710-718.

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]. 2021. Available at: https://www.hillrom.com/en/products/the-vest-system-105/. Accessed August 15, 2025.

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]. 11/02/2005. Available at: https://journal.chestnet.org/article/S0012-3692(16)50758-2/fulltext. Accessed August 15, 2025.

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. Cochrane Database Syst Rev. 2009;1:CD002011, DOI:10.1002/14651858. 01/24/2013 (Revised). Available at: http://www.thecochranelibrary.com [via subscription only]. Accessed August 15, 2025.

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.

Morrison L, Milroy S. Oscillating devices for airway clearance in people with cystic fibrosis. Cochrane Database Syst Rev. 2020;4 4):CD006842. 

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 information page. National Institutes of Health (NIH). [NINDS Web site]. 01/20/2023. Available at: https://www.ninds.nih.gov/health-information/disorders/inflammatory-myopathies. Accessed August 15, 2025.

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;8(1):19.

Noridian Healthcare Solutions. Local Coverage Determination (LCD) L33785. High frequency chest wall oscillation devices. [CMS Web site]. Original 10/01/2015, Revised 10/01/2022. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33785&ver=40&. Accessed August 15, 2025.

Noridian Healthcare Solutions. Local Coverage Article. (LCA) A52494. High frequency chest wall oscillation devices. [CMS Web site]. Original 10/01/2015, Revised 01/23/2025. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52494. Accessed August 15, 2025.

Noridian Healthcare Solutions. Local Coverage Article. A55426. Standard Documentation Requirements for All Claims Submitted to DME MACs. [CMS Web site]. Original 01/01/2017, Revised 01/01/2024. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=55426. Accessed August 15, 2025.


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.

Radtke, TT, Bni, LL, Bohnacker, PP. Acute effects of combined exercise and oscillatory positive expiratory pressure therapy on sputum properties and lung diffusing capacity in cystic fibrosis: a randomized, controlled, crossover trial. BMC Pulm Med. 2018;18(1).

Siafakas NM, Alexopoulou C, Bouros D. Respiratory muscle function in endocrine diseases. Monaldi Arch Chest Dis. 1999;54(2):154-159.

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:  https://www.accessdata.fda.gov/cdrh_docs/pdf/k993629.pdf. Accessed August 15, 2025.

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 Syst Rev. 2013; Issue 9. Art. No.: CD001401. DOI: 10.1002/14651858.CD001401.pub2.

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
A15.0Tuberculosis of lung
B91Sequelae of poliomyelitis
E74.02Pompe disease
E74.05Lysosome-associated membrane protein 2 [LAMP2] deficiency
E84.0Cystic fibrosis with pulmonary manifestations
E84.9Cystic fibrosis, unspecified
G12.0Infantile spinal muscular atrophy, type I [Werdnig-Hoffman]
G12.1Other inherited spinal muscular atrophy
G12.20Motor neuron disease, unspecified
G12.21Amyotrophic lateral sclerosis
G12.22Progressive bulbar palsy
G12.23Primary lateral sclerosis
G12.24Familial motor neuron disease
G12.25Progressive spinal muscle atrophy
G12.29Other motor neuron disease
G12.8Other spinal muscular atrophies and related syndromes
G12.9Spinal muscular atrophy, unspecified
G14Postpolio syndrome
G35.ARelapsing-remitting multiple sclerosis
​G35.B0
​Primary progressive multiple sclerosis, unspecified
​G35.B1
​Active primary progressive multiple sclerosis
​G35.B2
​Non-active primary progressive multiple sclerosis
​G35.C0
​Secondary progressive multiple sclerosis, unspecified
​G35.C1
​Active secondary progressive multiple sclerosis​
​G35.C2
​Non-active secondary progressive multiple sclerosis
​G35.D
​Multiple sclerosis, unspecified
​​G70.00
​Myasthenia gravis without (acute) exacerbation
​G70.01
​Myasthenia gravis with (acute) exacerbation​​​
G71.00Muscular dystrophy, unspecified
G71.01Duchenne or Becker muscular dystrophy
G71.02Facioscapulohumeral muscular dystrophy
G71.031Autosomal dominant limb girdle muscular dystrophy
G71.032Autosomal recessive limb girdle muscular dystrophy due to calpain-3 dysfunction
G71.033Limb girdle muscular dystrophy due to dysferlin dysfunction
G71.0340Limb girdle muscular dystrophy due to sarcoglycan dysfunction, unspecified
G71.0341Limb girdle muscular dystrophy due to alpha sarcoglycan dysfunction
G71.0342Limb girdle muscular dystrophy due to beta sarcoglycan dysfunction
G71.0349Limb girdle muscular dystrophy due to other sarcoglycan dysfunction
G71.035Limb girdle muscular dystrophy due to anoctamin-5 dysfunction
G71.038Other limb girdle muscular dystrophy
G71.039Limb girdle muscular dystrophy, unspecified
G71.09Other specified muscular dystrophies
G71.11Myotonic muscular dystrophy
G71.12Myotonia congenita
G71.13Myotonic chondrodystrophy
G71.14Drug induced myotonia
G71.19Other specified myotonic disorders
G71.20Congenital myopathy, unspecified
G71.21Nemaline myopathy
G71.220X-linked myotubular myopathy
G71.228Other centronuclear myopathy
G71.29Other congenital myopathy
G71.3Mitochondrial myopathy, not elsewhere classified
G71.8Other primary disorders of muscles
G72.0Drug-induced myopathy
G72.1Alcoholic myopathy
G72.2Myopathy due to other toxic agents
G72.41Inclusion body myositis [IBM]
G72.49Other inflammatory and immune myopathies, not elsewhere classified
G72.89Other specified myopathies
G72.9Myopathy, unspecified
G73.7Myopathy in diseases classified elsewhere
G80.0Spastic quadriplegic cerebral palsy
G82.50Quadriplegia, unspecified
G82.51Quadriplegia, C1-C4 complete
G82.52Quadriplegia, C1-C4 incomplete
G82.53Quadriplegia, C5-C7 complete
G82.54Quadriplegia, C5-C7 incomplete
J47.0Bronchiectasis with acute lower respiratory infection
J47.1Bronchiectasis with (acute) exacerbation
J47.9Bronchiectasis, uncomplicated
J98.6Disorders of diaphragm
M33.02Juvenile dermatomyositis with myopathy
M33.12Other dermatomyositis with myopathy
M33.22Polymyositis with myopathy
M33.92Dermatopolymyositis, unspecified with myopathy
M34.82Systemic sclerosis with myopathy
M35.03Sjogren syndrome with myopathy
Q33.4Congenital 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, with full anterior and/or posterior thoracic region receiving simultaneous external oscillation, includes all accessories and supplies, each​
Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

Revisions From 05.00.14s:
​09/30/2026
​​​This policy has been reissued in accordance with the Company's annual review process.​​​
​11/17/2025​

​This version of the policy will become effective on ​11/17/2025.​

​ 

The following ICD-10 codes have been deleted from this policy:

  • D81.810 Biotinidase deficiency
  • D81.82 Activated Phosphoinositide 3-kinase Delta Syndrome [APDS]
  • D84.1 Defects in the complement system

The following ICD-10 CM codes have been added to this policy:

  • G70.00 Myasthenia gravis without (acute) exacerbation
  • G70.01 Myasthenia gravis with (acute) exacerbation

Revisions From 05.00.14r:
10/01/2025​

​​This policy has been identified for the ICD-10 CM code update, effective 10/01/2025.

The following ICD-10 CM codes has been added to this policy:

  • G35.A  Relapsing-remitting multiple sclerosis
  • ​G35.B0 Primary progressive multiple sclerosis, unspecified
  • G35.B1  Active primary progressive multiple sclerosis
  • G35.B2​ Non-active primary progressive multiple sclerosis  
  • G35.C0 Secondary progressive multiple sclerosis, unspecified 
  • G35.C1 Active secondary progressive multiple sclerosis
  • G35.C2 Non-active secondary progressive multiple sclerosis
  • ​G35.D Multiple sclerosis, unspecified

The following ICD-10 CM code has been deleted from this policy: 

  • ​G35 Multiple sclerosis​​

Revisions From 05.00.14q:
10/17/2024​

This policy will be issued on 01/06​/2025 with a retroactively effective date of 10/17/2024.​
The following ICD-10 CM codes have been added to this policy:

  • ​E74.02 Pompe disease
  • E74.05 Lysosome-associated membrane protein 2 [LAMP2] deficiency
  • G72.41 Inclusion body myositis [IBM]
  • G72.49 Other inflammatory and immune myopathies, not elsewhere classified
  • G72.9​ Myopathy, unspecified

Revisions From 05.00.14p:
​05/01/2024
​​This policy has been reissued in accordance with the Company's annual review process.​​​
​07/31/2023​

This version of the policy will become effective 07/31/2023.

 

Face-to-Face Requirement language and documentation requirements have been removed for HCPCS codes A7025 and E0483 in accordance with the 2023 CMS New Final Rule on Face-to-Face Encounters.​


Revisions From 05.00.14o:
​10/01/2022
This version of the policy will become effective 10/01/2022.

This policy has been identified for the ICD-10 CM code update, effective 10/01/2022.

The following ICD-10 CM code narrative has been revised in this policy:
E0483​
FROM: High frequency chest wall oscillation system, includes all accessories and supplies, each
TO: High frequency chest wall oscillation system, with full anterior and/or posterior thoracic region receiving simultaneous external oscillation, includes all accessories and supplies, each

The following ICD-10 CM codes have been added:
G71.031 Autosomal dominant limb girdle muscular dystrophy
G71.032 Autosomal recessive limb girdle muscular dystrophy due to calpain-3 dysfunction
G71.033 Limb girdle muscular dystrophy due to dysferlin dysfunction
G71.0340 Limb girdle muscular dystrophy due to sarcoglycan dysfunction, unspecified
G71.0341 Limb girdle muscular dystrophy due to alpha sarcoglycan dysfunction
G71.0342 Limb girdle muscular dystrophy due to beta sarcoglycan dysfunction
G71.0349 Limb girdle muscular dystrophy due to other sarcoglycan dysfunction
G71.035 Limb girdle muscular dystrophy due to anoctamin-5 dysfunction
G71.038 Other limb girdle muscular dystrophy
G71.039 Limb girdle muscular dystrophy, unspecified​
D81.82 Activated Phosphoinositide 3-kinase Delta Syndrome [APDS]​​

Revisions From 05.00.14n:
​04/25/2022
This version of the policy will become effective 04/25/2022.

The intent of this policy remains unchanged, but the policy has been updated to ​revise medical coding.​

The following ICD CM codes have been removed from this policy:

G72.49 Other inflammatory and immune myopathies, not elsewhere classified
M05.40 Rheumatoid myopathy with rheumatoid arthritis of unspecified site
M05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sites​​

Revisions From 05.00.14m:
​10/01/2021
​This policy has been identified for the ICD-10 CM code update, effective 10/01/2021.

The following ICD-10 CM narratives have been revised in this policy:

G71.20:
FROM: Congenital myopathy, unspecified
TO: Congenital myopathy, unspecified
​
M35.03:
​FROM: Sicca syndrome with myopathy
TO: Sjogren syndrome with myopathy

Revisions From 05.00.14l:
​09/08/2021
​This policy has been reissued in accordance with the Company's annual review process.​​
10/01/2020This policy has been identified for the ICD-10 CM code update, effective 10/01/2020.

The following ICD-10 code has been deleted:
G71.2  Congenital myopathies

The following ICD-10 codes have been added:
G71.20  Congenital myopathy, unspecified
G71.21  Nemaline myopathy
G71.220  X-linked myotubular myopathy
G71.228  Other centronuclear​ myopathy
G71.29  Other congenital myopathy​

Revisions From 05.00.14k:
08/03/2020This version of the policy will become effective 08/03/2020.

In accordance with the Centers for Medicare & Medicaid Services' (CMS) Final Rule 1713 (84 Fed. Reg Vol 217), a face-to-face encounter has been added for specified HCPCS code:

A7025 High frequency chest wall oscillation system vest, replacement for use with patient-owned equipment, each

Revisions From 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

Revisions From 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

Revisions From 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.
11/17/2025
11/17/2025
9/30/2026
05.00.14
Medical Policy Bulletin
Commercial
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2026 Independence Blue Cross

Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.