Scenario 3: My cough assist device was denied.
Mechanical Insufflation Exsufflation (MI-E) devices such as the Respironics CoughAssist T70, referred to by CMS (Centers for Medicare & Medicaid Services) as "E0482 Cough-Stimulating Device, Alternating Positive and Negative Airway Pressure" are sometimes denied coverage by Medicare and other insurance companies. Below are the criteria that most payers follow for approving MI-E devices. If you are advocating to get an MI-E device and your clinician is not experienced with Neuromuscular Disease (NMD) and/or this equipment, you may wish to share this information.
Approval Criteria:
First, ensure that you have had a face-to-face exam prior to the clinician writing the order for the MI-E device.
Your clinician must document that:
But what do you do if you clinician won’t even order one, says that you don’t need one?
Some in the Breathe community have found that a pulmonary specialist is not needed and that their primary care provider can order a mechanical cough assistance device by following the criteria in the bullet points listed above. The quote below details the clinical parameters seen on pulmonary function testing (PFT) that show an individual living with an NMD needs a mechanical cough assistance device. If your primary care provider can get results from your most recent PFT or order a new PFT, the following can be used to determine if you have cough impairment.
“Vital capacity, maximum expiratory pressure (MEP), and peak cough flow (PCF) are the commonly used markers of cough function. In adolescents and adults, cough function is considered impaired when vital capacity is less than 50% predicted, PCF is less than 270L per minute, or the MEP is less than 60cm H2O (LoMauro, Romei, D’Angelo, & Aliverti, 2014; Man et al., 2003; Szeinberg et al., 1988; Tzeng & Bach, 2000). Severe chest infections were predicted by vital capacity less than 30% and PCF less than 160L per minute (Dohna-Schwake, Ragette, Teschler, Voit, & Mellies, 2006). These parameters have been adopted in disease-specific guidelines (Birnkrant et al., 2018) as well as by US Centers for Medicare and Medicaid Services as criteria for approval of mechanical insufflation/exsufflation devices.”
Reference: Mayer, Oscar Henry, editor. Pulmonary Assessment and Management of Patients With Pediatric Neuromuscular Disease. Academic Press, 2023.
To learn more about cough in NMD, please see our webpage Cough in Neuromuscular Disease.
Mechanical Insufflation Exsufflation (MI-E) devices such as the Respironics CoughAssist T70, referred to by CMS (Centers for Medicare & Medicaid Services) as "E0482 Cough-Stimulating Device, Alternating Positive and Negative Airway Pressure" are sometimes denied coverage by Medicare and other insurance companies. Below are the criteria that most payers follow for approving MI-E devices. If you are advocating to get an MI-E device and your clinician is not experienced with Neuromuscular Disease (NMD) and/or this equipment, you may wish to share this information.
Approval Criteria:
First, ensure that you have had a face-to-face exam prior to the clinician writing the order for the MI-E device.
Your clinician must document that:
- you have a Neuromuscular Disease (NMD)
- your condition is causing a significant impairment of chest wall and/or diaphragmatic movement, such that it results in an inability to clear retained secretions.
But what do you do if you clinician won’t even order one, says that you don’t need one?
Some in the Breathe community have found that a pulmonary specialist is not needed and that their primary care provider can order a mechanical cough assistance device by following the criteria in the bullet points listed above. The quote below details the clinical parameters seen on pulmonary function testing (PFT) that show an individual living with an NMD needs a mechanical cough assistance device. If your primary care provider can get results from your most recent PFT or order a new PFT, the following can be used to determine if you have cough impairment.
“Vital capacity, maximum expiratory pressure (MEP), and peak cough flow (PCF) are the commonly used markers of cough function. In adolescents and adults, cough function is considered impaired when vital capacity is less than 50% predicted, PCF is less than 270L per minute, or the MEP is less than 60cm H2O (LoMauro, Romei, D’Angelo, & Aliverti, 2014; Man et al., 2003; Szeinberg et al., 1988; Tzeng & Bach, 2000). Severe chest infections were predicted by vital capacity less than 30% and PCF less than 160L per minute (Dohna-Schwake, Ragette, Teschler, Voit, & Mellies, 2006). These parameters have been adopted in disease-specific guidelines (Birnkrant et al., 2018) as well as by US Centers for Medicare and Medicaid Services as criteria for approval of mechanical insufflation/exsufflation devices.”
Reference: Mayer, Oscar Henry, editor. Pulmonary Assessment and Management of Patients With Pediatric Neuromuscular Disease. Academic Press, 2023.
To learn more about cough in NMD, please see our webpage Cough in Neuromuscular Disease.