This document addresses the use of high frequency chest compression devices (HFCC) (such as the Vest^™ Airway Clearance System or the Medpulse^® Respiratory Vest System) as an alternative to conventional chest physical therapy to promote the clearance of respiratory secretions in individuals with impaired ability to cough or otherwise expel them on their own.

Note: Other types of mucous clearance systems are not addressed within this document (for example, the Flutter^® Mucous Clearance System, the Acapella^® Vibratory PEP Therapy System, etc.). See Definitions section for further information.

Note: For information regarding intrapulmonary percussive ventilation devices, please refer to:

• DME.00012 Intrapulmonary Percussive Ventilation Devices

Clinical Indications

Medically Necessary:

Initial use of a high frequency chest compression device (see index for examples) is considered medically necessary when ALL of the following are met:

1. The device is cleared by the U.S. Food and Drug Administration; and
2. There is documented need for airway clearance; and
3. The individual has one of the following diagnoses:
   1. Cystic fibrosis; or
   2. Chronic bronchiectasis; or
   3. Chronic neuromuscular disorder (for example, but not limited to, muscular dystrophy, spinal muscular atrophy, multiple sclerosis, quadriplegia, and amyotrophic lateral sclerosis) affecting the ability to cough or clear respiratory secretions with prior history of pneumonia or other significant worsening of pulmonary function; and
4. There is documentation of i) failure of or ii) inability to use other airway clearance therapies including manual chest physical therapy due to one or more of the following:
   1. There are 2 or more individuals with cystic fibrosis, chronic bronchiectasis, or chronic neuromuscular disorder (meeting criteria above) in the family; or
   2. The caregiver is unable (physically or mentally) to perform chest physical therapy at the required frequency; or
   3. There is no available parental or partner resource to perform chest physical therapy; and
5. There is documentation of a trial during which the affected individual and the family (when applicable) demonstrates ability to comply (see the following statement for details).

Continued use of a high frequency chest compression device is considered medically necessary when ongoing use, (that is, compliance with use) is documented at 6 month to 12 month intervals. (Note: For high frequency chest compression devices with usage meters, documentation should reflect use, in general, at least 67% of the prescribed time).

Not Medically Necessary:

High frequency chest compression devices are considered not medically necessary when the above criteria have not been met.

High frequency chest compression device replacement or upgrade is considered not medically necessary when requested for convenience or to upgrade to newer technology when the current components remain functional.

All other indications for high frequency chest compression are considered not medically necessary, including, but not limited to, chronic obstructive pulmonary disease.