REVIEW REQUEST FOR
Oscillatory Devices for Airway Clearance including
High Frequency Chest Compression and
Intrapulmonary Percussive Ventilation (IPV)
Provider Data Collection Tool Based on Medical Policy DME.00012
Policy Last Review Date: 02/05/2015
Policy Effective Date: 04/07/2015
Provider Tool Effective Date: 04/16/13
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s 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 Code(s) ( if known):
Please check all that apply to the individual:
Intrapulmonary Percussive Ventilation (IPV®) Devices
Request is for intrapulmonary percussive ventilation devices (IPV), also known as Percussionaire, as an airway clearance
treatment
High Frequency Chest Compression Devices
Section I – Initial Request:
Request is for initial use of a FDA-approved high frequency chest compression (HFCC) device (Please indicate device)
Vest™ Airway Clearance System
ABI Vest®
ThAIRapy Vest®
ThAIRapy Bronchial Drainage System®
Medpulse® Respiratory Vest System
Other: (please list)
There is documentation of an initial trial during which the affected individual and the family (when applicable) have
demonstrated compliance with the device
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REVIEW REQUEST FOR
Oscillatory Devices for Airway Clearance including
High Frequency Chest Compression and
Intrapulmonary Percussive Ventilation (IPV)
Provider Data Collection Tool Based on Medical Policy DME.00012
Policy Last Review Date: 02/05/2015
Policy Effective Date: 04/07/2015
Provider Tool Effective Date: 04/16/13
The individual has: (Check all that apply)
There is documented need for 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 or inability to use other airway clearance therapies including manual chest physical
therapy due to: (Check all that apply)
Two or more individuals with cystic fibrosis, chronic bronchiectasis or chronic neuromuscular disorder
in the family
The caregiver is unable [physical or mental] to perform chest physical therapy at the required frequency
There is no availabile parental or partner resource to perform chest physical therapy
Other: (please list)
Individual 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 for extension of previous authorization
There is documentation of ongoing use at 6 months to 12 month intervals (Note: for devices with usage meters,
documentation should reflect use at least 67% of the prescribed time).
Other: (please list)
Other: (please list)
Section III – Device Upgrade
Request is for high frequency chest compression (HFCC) device replacement or upgrade for convenience or to upgrade to
newer technology
Current components remain functional
Reason for replacement or upgrade is:
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REVIEW REQUEST FOR
Oscillatory Devices for Airway Clearance including
High Frequency Chest Compression and
Intrapulmonary Percussive Ventilation (IPV)
Provider Data Collection Tool Based on Medical Policy DME.00012
Policy Last Review Date: 02/05/2015
Policy Effective Date: 04/07/2015
Provider Tool Effective Date: 04/16/13
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 the health plan or its
designees 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
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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