Insurance coverage for HFCWO
Insurance coverage for high frequency chest wall oscillation (HFCWO) will vary, based on each insurer’s policies, the diagnosed disease or medical condition, and the patient’s previous treatment history for impaired airway clearance.
Following are reimbursement requirements typically seen from several of the most prominent health care payers in the United States. If you are a clinician, patient or caregiver with questions about a specific insurer’s coverage of HFCWO, contact the Reimbursement Team at Electromed, Inc. for assistance in determining coverage.
Medicare coverage for HFWCO
As with many medical devices, Medicare’s policies for HFCWO devices tend to be a standard other insurance providers either follow, or use as a baseline with some modifications. Medicare routinely covers HFCWO (provided certain conditions are met) for diagnoses that include:
- Cystic fibrosis
- Post-polio syndrome
- Acid maltase deficiency
- Anterior horn cell diseases
- Multiple sclerosis
- Hereditary muscular dystrophy
- Myotonic disorders
- Paralysis of the diaphragm
Except for bronchiectasis treatment, Medicare will cover an HFCWO prescription for all of the diseases and conditions listed above, with one requirement:
- Documentation (i.e., chart notes) indicating that a lower-cost airway clearance therapy was tried, and why it failed to mobilize secretions.
For bronchiectasis, Medicare will cover HFCWO when the physician can provide and confirm:
- A CT scan confirming the diagnosis.
- Daily productive cough for at least six (6) consecutive months (documented in two (2) physician notes at least six (6) months apart), or physician notes documenting exacerbations treated by antibiotics at least three (3) times in the past year.
- Documentation that a lower-cost airway clearance therapy was tried and failed. (Medicare’s four geographic regions differ slightly on the other therapy or therapies that must be tried and proven inadequate).
Medicare requires that all prescription orders and progress notes be signed by the prescribing physician. It must be a dated, legible, handwritten, full signature with credentials, or electronically signed and dated. Stamped signatures are not acceptable.
IMPORTANT: Medicare has approved HFCWO therapy for hundreds of diagnoses besides those listed above. However, Medicare currently determines coverage on those other diagnoses on a case-by-case basis. Also, Medicare might deny an initial HFCWO prescription order for those other diagnoses before approving it on appeal. The Reimbursement Team at Electromed submits appeals documentation to Medicare and other insurers, and coordinates the appeals process on behalf of clinicians and their patients.
Private insurance coverage for HFCWO
Health plans and insurance companies often follow Medicare’s lead when it comes to providing coverage for “durable medical equipment,” including HFCWO devices. In fact, many private payers regard Medicare’s reimbursement stance as a “seal of approval,” indicative of a treatment found to be both medically effective and cost-effective.
Most private payers require prior authorization before an HFCWO prescription will be reimbursed. Most also require that a lower-cost airway clearance therapy have been tried and failed prior to approving HFCWO for reimbursement. Some private payers also have unique documentation requirements, such as use of their own forms when submitting for authorization.
Medicaid coverage for HFCWO
State and local government agencies operate Medicaid and other programs for low-income and disabled individuals and their families. While these programs tend to track Medicare’s evolving policies on coverage and reimbursement, they do not automatically follow Medicare guidelines.
Thus, coverage and reimbursement for HFCWO among government-run insurance programs at the state and local level can vary considerably. Some require authorization prior to approving reimbursement. Some require specific types of documentation from a prescribing physician. Clinicians, patients and caregivers often find it very helpful to work with an HFCWO manufacturer, such as Electromed, to manage the process of authorization and reimbursement with government payers at the state and local level.
VA coverage for HFCWO
The Veterans Health Administration (VA) has its own process for authorizing and reimbursing for HFCWO and other medical devices. When a VA doctor prescribes HFCWO, that prescription gets reviewed internally, based on the device’s potential to reduce long-term health risks and costs.
Once an HFCWO prescription passes muster inside the VA, the VA will purchase the device directly from an approved manufacturer. Electromed, maker of the SmartVest® Airway Clearance System, is one of the VA’s contracted vendors for HFCWO and has preferred status as a small business when it comes to U.S. government purchasing.