Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut DME.00012 Intrapulmonary Percussive Ventilation Devices Form

Effective Date

06/28/2023

Last Reviewed

05/11/2023

Original Document

  Reference



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.

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