Aetna Commercial Clinical Policy

Aetna Suction Pumps Form

Effective Date

04/27/2001

Last Reviewed

07/12/2023

Original Document

  Reference



Background for this Policy

A portable home model suction pump is a light-weight, compact, electric aspirator designed for upper respiratory, oral pharyngeal and tracheal suction for use in the home. Use of the device does not require technical or professional supervision. A stationary home model respiratory suction pump is an electric aspirator designed for oropharyngeal and tracheal suction.

A portable or stationary home model gastric suction pump is an electric aspirator designed to remove gastrointestinal secretions.

A closed system tracheal suction catheter is a type of suction catheter that is protected by an outer sheath. It is connected to the ventilator circuit of a person on mechanical ventilation and left in place. Suctioning is accomplished without disconnection from ventilation.

A tracheal suction catheter is a long, flexible catheter.

An oropharyngeal catheter is a short, rigid (usually) plastic catheter of durable construction.

Wound suction is provided with an integrated system of components. This system contains a pump and dressing sets. It does not include a separate collection canister, a defining component of Negative Pressure Wound Therapy (NPWT). Instead, exudate is retained in the dressing materials. Wound suction systems that do not contain all of the required components are not classified as wound suction systems.

A portable home model suction pump for use on wounds describes a suction pump for wounds which provides controlled subatmospheric pressure that is designed for use with dressings, without a canister.

An absorptive wound dressing for use with a portable home model suction pump describes an allowance for dressing sets which are used in conjunction with a stationary or portable suction pump but not used with a canister. Each of these absorptive wound dressings is used for a single, complete dressing change, and contains all necessary components, including but not limited to non-adherent porous dressing, drainage tubing, and an occlusive dressing which creates a seal around the wound site for maintaining subatmospheric pressure at the wound. These dressing sets are selected based upon wound size using the smallest size necessary to cover the wound. For multiple wounds located close together, a single large dressing must be used rather than multiple smaller dressing sets if it is possible to fit the wounds under a single larger dressing set.

A disposable wound suction including dressing and accessories describes a disposable wound suction device. Suction is developed through the use of any type of mechanism. This device includes all components, accessories and dressings.

Scope of Policy

This Clinical Policy Bulletin addresses suction pumps.

Medical Necessity

Aetna considers the following suction pumps and associated supplies medically necessary:

Respiratory Suction Pump

  • Home model respiratory suction machines as durable medical equipment for members who have difficulty raising and clearing secretions secondary to
    • any
  • of the following conditions:
  • Cancer or surgery of the throat or mouth;
    • or
  • Dysfunction of the swallowing muscles;
    • or
  • Tracheostomy;
    • or
  • Unconsciousness or obtunded state.

    • Aetna considers respiratory suction pumps experimental and investigational for all other indications because of insufficient evidence of effectiveness for other indications.

  • Tracheal suction catheters and sterile water/saline as supplies for suction pumps.
  • Closed system catheters when
    • all
  • of the following are met:
  • The member has a tracheostomy;
    • and
  • The member requires the use of a medically necessary respiratory suction pump, as described above, for tracheostomy suctioning;
    • and
  • The member requires the use of a medically necessary ventilator.
  • Tracheal suction catheters other than closed system catheters when
    • all
  • of the following are met:
  • The member has a tracheostomy;
    • and
  • The member requires the use of a medically necessary respiratory suction pump, as described above, for tracheostomy suctioning.
  • More than three tracheal suction catheters other than closed system per day are considered not medically necessary for tracheostomy suctioning.
  • In most cases, in the home setting, sterile catheters are considered medically necessary only for tracheostomy suctioning.
  • Three suction catheters per day are considered medically necessary for tracheostomy suctioning, unless additional documentation is provided. When a tracheal suction catheter is used in the oropharynx, which is not sterile, the catheter can be re-used if properly cleansed and/or disinfected. In this situation the medical necessity for more than 3 catheters per week would require additional documentation.
  • An oral interface used with a respiratory suction pump is considered not medically necessary because it is not used to remove secretions for the indications described above.
  • Sterile saline solution when used to clear a suction catheter after tracheostomy suctioning. It is not usually considered medically necessary for oropharyngeal suctioning.
  • The following supplies for use with a suction pump:
  • Disposable or non-disposable canister used with suction pump;
  • Oropharyngeal suction catheters;
  • Tubing used with suction pump.

    • When a suction pump is used for tracheal suctioning, other supplies (e.g., basins, cups, gloves, solutions, etc.) included with the tracheal care kit are considered medically necessary. When a suction pump is used for oropharyngeal suctioning, these other supplies are not considered medically necessary.

    Gastric Suction Pump

  • Use of a gastric suction pump and related supplies for members who are unable to empty gastric secretions through normal gastrointestinal functions. A gastric suction pump is used to remove gastrointestinal fluids under continuous or intermittent suction via a tube. Gastric suction pumps are considered experimental and investigational for all other indications.
  • Supplies (tubing, tape, dressings, etc.) for use with a medically necessary gastric suction pump.

    • Wound Suction Pumps

  • Use of suction on wounds only in those clinical scenarios where the quantity of exudate exceeds the capacity of conservative measures such as surgical dressings and wound fillers to contain it. However, wound suction to remove exudate can be accomplished with the use of disposable, suction devices, which are considered supplies, or with portable home model suction pumps, which are considered DME.
  • Supplies (dressings, tubing, etc.) when they are used with a medically necessary portable home model suction pump for use on wounds.
    • Note:

    When a disposable suction device alternative exists, it is not considered medically necessary to use a portable home model suction pump for use on wounds. Note: Disposable suction devices are not covered under plans that exclude supplies.

    Policy Limitations and Exclusions

    Saline used for tracheal lavage is considered a supply, and is not covered under plans that exclude supplies.

    All items used with any suction pump, such as tracheal suction catheters, sterile water, saline used for suctioning, dressings, gastric tubes, etc. (not all-inclusive) are considered to be supplies for durable medical equipment.

    Disposable wound suction devices and related supplies are considered supplies and are not considered DME; they are not covered under plans that exclude supplies.