DME.00012 Intrapulmonary Percussive Ventilation Devices Form

This document addresses the use of intrapulmonary percussive ventilation devices (IPV) (such as the Percussionaire^® family of devices and the Volara^™ 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.).

Note: For information regarding high frequency chest compression devices, please refer to:

• CG-DME-43 High Frequency Chest Compression Devices for Airway Clearance

Position Statement

Investigational and Not Medically Necessary:

Intrapulmonary percussive ventilation devices are considered investigational and not medically necessary for all indications, including but not limited to the following:

• Cystic fibrosis; or
• Bronchiectasis; or
• Chronic obstructive pulmonary disease; or
• Neuromuscular conditions associated with retained airway secretions or atelectasis.