REVIEW REQUEST FOR
Oscillatory Devices for Airway Clearance including
High Frequency Chest Compression (Vest™ Airway
Clearance System) and Intrapulmonary Percussive Ventilation (IPV)
Provider Data Collection Tool Based on Medical Policies 1.01.15; DME.00012
1.01.15 Policy Last Review Date: 12/7/2011
DME.00012 Policy Last Review Date: 02/17/2011
1.01.15 Policy Effective Date: 01/01/2012
Policy Effective Date: 04/13/2011
Provider Tool Effective Date: 03/22/2011
Member Name:
Date of Birth:
Insurance Identification Number:
Member Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Facility Name:
Facility ID Number:
Facility Address:
Date/Date Range of Service:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis (ICD-9) if known):
Please check all that apply to the member:
Type of Oscillatory Device
The Bird IPV® Noncontinuous Ventilator
FLUTTER® Mucus Clearance Device
The ThAIRapy Bronchial Drainage System or Vest™ Airway Clearance System
The Acapella® device
The RC Cornet™ Mucus Clearing Device
Other Device ______________________________
The member has: (Check all that apply)
Documented need of airway clearance
Cystic fibrosis (CF)
Chronic bronchiectasis
Chronic neuromuscular disorder affecting the ability to cough or clear respiratory secretions and prior history of
pneumonia or other significant worsening of pulmonary function
Documentation of failure of other methods or inability to use other airway clearance therapies including chest
physical therapy due to: (Check all that apply)
Two or more children with cystic fibrosis in the family
Inability of the caregiver [physical or mental] to perform chest physical therapy at the required frequency
No availability of parental or partner resource to perform chest physical therapy
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REVIEW REQUEST FOR
Oscillatory Devices for Airway Clearance including
High Frequency Chest Compression (Vest™ Airway
Clearance System) and Intrapulmonary Percussive Ventilation (IPV)
Provider Data Collection Tool Based on Medical Policies 1.01.15; DME.00012
1.01.15 Policy Last Review Date: 12/7/2011
DME.00012 Policy Last Review Date: 02/17/2011
1.01.15 Policy Effective Date: 01/01/2012
Policy Effective Date: 04/13/2011
Provider Tool Effective Date: 03/22/2011
Other: (please list)
Member has history of : (check all that apply)
Unstable head or neck injury
Active hemorrhage with hemodynamic instability
Subcutaneous emphysema
Recent epidural, spinal fusion, or spinal anesthesia
Recent skin grafts or flaps
Burns, open wounds and skin infections of the thorax
Recently placed transvenous pacemaker or subcutaneous pacemaker
Suspected pulmonary tuberculosis
Lung contusion
Bronchospasm
Osteomyelitis of the ribs
Osteoporosis
Coagulopathy
Complaint of significant chest wall pain
Chronic obstructive pulmonary disease
Other: (please list)
Section II – Continued Use Request: (SECTION I MUST ALSO BE COMPELTED)
Request is for approval after initial trial or extension of previous authorization
There is affected member/family compliance with the device as evidenced by an initial trial period and: (Check all
that apply)
This is monitored by a report at 6-12 months interval which reviews monthly usage of device (for device
with usage meters)
The report documents sufficient use to be clinically effective (67% or more of the prescribed time)
Other: (please list)
Request is for alternative method of airway clearance as a result of intolerance to the device or failure to comply with usage
meter checks. Please describe:
Other: (please list)
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that Anthem may perform a
routine audit and request the medical documentation to verify the accuracy of the information reported on this form.
_____________________________________________________________
Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
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