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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o). The rules say that high frequency chest wall oscillation devices (HFCWODs) are covered when they are medically necessary for enrollees who have: - cystic fibrosis; or - bronchiectasis that has been confirmed by CT scan; or - one of these neuromuscular diseases: post-polio, acid maltase deficiency, anterior horn cell diseases, multiple sclerosis, quadriplegia, hereditary muscular dystrophy, myotonic disorders, other myopathies, or paralysis of the diaphragm. Medical records must show failure of standard treatments to clear secretions. The rules also say that chronic bronchitis and chronic obstructive pulmonary disease (COPD) do not meet criteria for coverage when there is no diagnosis of bronchiectasis. You can find these rules in the Medicare Local Coverage Determination (LCD) L33785, High Frequency Chest Wall Oscillation Devices. This LCD is effective for services provided on or after July 1, 2016. High frequency chest wall oscillation devices (HFCWO) (E0483) are covered for beneficiaries who meet: A. Criterion 1, 2, or 3, and B. Criterion 4 1. There is a diagnosis of cystic fibrosis (refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses). 2. There is a diagnosis of bronchiectasis (refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses) which has been confirmed by a high resolution, spiral, or standard CT scan and which is characterized by: a. Daily productive cough for at least 6 continuous months; or b. Frequent (i.e., more than 2/year) exacerbations requiring antibiotic therapy. Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed diagnosis of bronchiectasis do not meet this criterion. 3. The beneficiary has one of the following neuromuscular disease diagnoses (refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses): Post-polio Acid maltase deficiency Anterior horn cell diseases Multiple sclerosis Quadriplegia Hereditary muscular dystrophy Myotonic disorders Other myopathies Paralysis of the diaphragm 4. There must be well-documented failure of standard treatments to adequately mobilize retained secretions. You can find this information in Local Coverage Determination (LCD): High Frequency Chest Wall Oscillation Devices (L33785). IPV is a mechanized form of chest physical therapy. Instead of a therapist clapping or slapping the patient's chest wall, the IPV delivers mini-bursts (more than 200 per minute) of respiratory gasses to the lungs via a mouthpiece. Its intended purpose is to mobilize endobronchial secretions and diffuse patchy atelectasis. The patient controls variables such as inspiratory time, peak pressure and delivery rates. You can find this information in National Coverage Determination (NCD) for Intrapulmonary Percussive Ventilator (IPV) (240.5).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.