OAR 410-122-0211: Cough Stimulating Device

(1) Indications and Limitations of Coverage and Medical Appropriateness: The Division may cover a cough stimulating device, alternating positive and negative airway pressure, for a client who meets the following criteria: (a) The client has been diagnosed with a neuromuscular disease as identified by one of the following diagnosis codes: (A) Late effects of acute poliomyelitis; (B) Cystic fibrosis; (C) Werdnig-Hoffmann disease—anterior horn cell disease unspecified; (D) Multiple sclerosis — quadriplegia and quadriparesis; (E) Myoneural disorders; (F) Disorders of diaphragm; (G) Fracture of vertebral column, cervical, or dorsal (thoracic); (H) Late effect of spinal cord injury; (I) Late effect of injury to a nerve root or roots, spinal plexus or plexuses and other nerves of trunk; (J) Spinal cord injury without evidence of spinal bone injury, cervical or dorsal (thoracic); and (b) Standard treatment such as chest physiotherapy (e.g., chest percussion and postural drainage, etc.) has been tried and documentation supports why these modalities were not successful in adequately mobilizing retained secretions; or (c) Standard treatment such as chest physiotherapy (e.g., chest percussion and postural drainage, etc.) is contraindicated and documentation supports why these modalities were ruled out; and (d) The condition is causing a significant impairment of chest wall or diaphragmatic movement, such that it results in an inability to clear retained secretions. (2) Prior Authorization (PA): (a) PA is required for the cough stimulating device (E0482); (b) Submit specific documentation from the treating practitioner that supports coverage criteria in this rule are met and may include, but is not limited to, evidence of any of the following: (A) Poor, ineffective cough; (B) Compromised respiratory muscles from muscular dystrophies or scoliosis; (C) Diaphragmatic paralysis; (D) Frequent hospitalizations or emergency department/urgent care visits due to pneumonias. (3) Reimbursement: (a) The Division shall purchase or rent on a monthly basis (limited to the lowest cost alternative); (b) The cough stimulating device (E0482) is considered purchased after no more than ten (10) months of rent; (c) The Division may cover replacement of the interface (A7020) once every six (6) months with continued use of a client-owned cough stimulating device. (4) Payment includes: (a) The rental fee includes all equipment, supplies (including the interface), services, routine maintenance, and necessary training for the effective use and operation of the device; (b) The initial purchase fee includes all equipment, supplies (including the interface), services, and necessary training for the effective use and operation of the device. (5) E0482 may be covered for a client residing in a nursing facility. (6) Documentation Requirements: (a) For services requiring prior authorization, submit documentation that supports coverage criteria in this rule are met; (b) Documentation and medical records to support the client meets all criteria and conditions of coverage in this rule must be kept on file with the DMEPOS provider and shall be available to the Division upon request. (7) Procedure Codes: (a) E0482- Cough stimulating device, alternating positive and negative airway pressure – PA (b) A7020- Interface for cough stimulating device, includes all components, replacement only.