Reimbursement Coverage for AffloVest
Help to get your Airway Clearance Therapy paid for
Navigating the reimbursement process from an insurance company can be frustrating and complicated at times. Coverage criteria and documentation requirements can vary for patient to patient, largely depending on their medical condition and their health insurance carrier and plan. All High Frequency Chest Wall Oscillation (HFCWO) airway clearance therapy vests fall under the E0483 HCPCS and require a doctor’s prescription for use.
The AffloVest also requires a doctor’s prescription for treatment by HFCWO. The AffloVest has received the FDA’s 510k clearance for U.S. market availability, and is approved for Medicare, Medicaid, and private health insurance reimbursement under the Healthcare Common Procedure Coding System(HCPCS) code E0483 – High Frequency Chest Wall Oscillation. The AffloVest is available through the U.S Department of Veterans Affairs/Tricare. Patients must qualify for coverage and meet their individual insurance’s eligibility requirements.
Private insurance carriers may or may not follow Medicare’s coverage policies and may also require prior authorization as a condition of coverage. Some may require specific documentation or may not cover all of the diagnoses in Medicare’s coverage guidelines. Most will also require that alternative, standard airway clearance therapies have been tried and failed prior to approving HFCWO therapy for coverage. It is best to contact your individual insurance carrier or have the medical equipment company you are working with contact the insurance directly to request all required documentation needed for insurance coverage.
According to the Medicare LCD (other insurances may vary), the following must all be well documented in the Medical Record itself:
Patient must be diagnosed with a condition such as Bronchiectasis (which has been confirmed by a CT scan), or Cystic Fibrosis, Multiple Sclerosis, Muscular Dystrophy or other neuromuscular diseases (View a full list of Medicare approved ICD10 Codes for HFCWO E0483 here).
- Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed diagnosis of bronchiectasis do not meet this criterion.
REASON(S) FOR ORDERING AFFLOVEST
If the primary diagnosis is Bronchiectasis, Signs & Symptoms of one of the following must be met:
- Daily productive (mucus) cough for at least 6 continuous months in the year prior to the date of the order; OR
- Frequent (i.e. more than 2/year) exacerbations/chest infections (such as Pneumonia) requiring antibiotic therapy in the year prior to the date of the order
If Cystic Fibrosis or an approved Neuromuscular diagnosis is primary: chart notes to support the diagnosis are required.
TRIED AND FAILED AIRWAY CLEARANCE
Documentation (chart notes) of another airway clearance treatment tried to mobilize secretions and clearly indicating that the other device has failed.
- Which Airway Clearance Therapies have been “tried and failed” for the patient?
- CPT (Manual or Percussor) • PEP (Acapella®/Flutter®) • CoughAssist • Autogenic Drainage • “Huff Cough” • Postural Drainage • use of Mucomist (Acetylcysteine), and hypertonic saline can be used for tried and failed as long as there is documentation these were used for airway clearance and ineffective.
- Include all reasons why the above therapy is ineffective or didn’t help for the mobilization of secretions.
Recommendation for AffloVest HFCWO therapy including frequency of use for treatments as recommended by the practitioner.
Once delivered, Continued Need and Continued Use criteria (just like all other forms of durable medical equipment (DME) must be met. This is not the same as compliance like a CPAP device.
This article is meant to offer general coverage information, coding and payment information for prescriptions associated with use of high frequency chest wall oscillation. This article is not meant to serve as legal guidance, or formal advice on how to code, complete, or submit an insurance claim for payment. It is the provider’s responsibility to determine coverage and submit appropriate codes and any charges. This article is based on the medical necessity of the services and supplies provided, the requirements of insurance carriers and any other third-party payers, and any local, state or federal laws that apply to the products and services rendered. Given the constant change in public and private reimbursement coverage, we do not guarantee the accuracy or timeliness of this information.