Respiratory Suction Pump:
Aetna considers home model respiratory suction machines medically necessary durable medical equipment for members who have difficulty raising and clearing secretions secondary to any of the following conditions:
Aetna considers respiratory suction pumps experimental and investigational for all other indications because of insufficient evidence of effectiveness for other indications.
Aetna considers tracheal suction catheters and sterile water/saline medically necessary supplies for suction pumps.
Closed system catheters are considered medically necessary when all of the following are met:
Tracheal suction catheters other than closed system catheters are considered medically necessary necessary when all of the following are met:
More than three tracheal suction catheters other than closed system per day are considered not medically necessary for tracheostomy suctioning.
In most cases, in the home setting, sterile catheters are considered medically necessary only for tracheostomy suctioning. Three suction catheters per day are considered medically necessary for tracheostomy suctioning, unless additional documentation is provided. When a tracheal suction catheter is used in the oropharynx, which is not sterile, the catheter can be re-used if properly cleansed and/or disinfected. In this situation the medical necessity for more than 3 catheters per week would require additional documentation.
An oral interface used with a respiratory suction pump is not used to remove secretions for the medically necessary indications described above.
Aetna considers sterile saline solution medically necessary when used to clear a suction catheter after tracheostomy suctioning. It is not usually considered medically necessary for oropharyngeal suctioning.
Aetna considers the following supplies medically necessary for use with a suction pump:
When a suction pump is used for tracheal suctioning, other supplies (e.g., basins, cups, gloves, solutions, etc.) included with the tracheal care kit are considered medically necessary. When a suction pump is used for oropharyngeal suctioning, these other supplies are not considered medically necessary.
Gastric Suction Pump
A gastric suction pump is used to remove gastrointestinal fluids under continuous or intermittent suction via a tube. Use of a gastric suction pump and related supplies is considered medically necessary for members who are unable to empty gastric secretions through normal gastrointestinal functions. Gastric suction pumps are considered experimental and investigational for all other indications.
Supplies (tubing, tape, dressings, etc.) are considered medically necessary for use with a medically necessary gastric suction pump.
Wound Suction Pumps
Use of suction on wounds is only considered medically necessary in those clinical scenarios where the quantity of exudate exceeds the capacity of conservative measures such as surgical dressings and wound fillers to contain it. However, wound suction to remove exudate can be accomplished with the use of disposable, suction devices, which are considered supplies, or with portable home model suction pumps, which are considered DME. When a disposable suction device alternative exists, it is not considered medically necessary to use a portable home model suction pump for use on wounds. Note: Disposable suction devices are not covered under plans that exclude supplies.
Supplies (dressings, tubing, etc.) are considered medically necessary when they are used with a medically necessary portable home model suction pump for use on wounds.
Saline used for tracheal lavage is considered a supply, and is not covered under plans that exclude supplies.
All items used with any suction pump, such as tracheal suction catheters, sterile water, saline used for suctioning, dressings, gastric tubes, etc. (not all-inclusive) are considered to be supplies for durable medical equipment.
Disposable wound suction devices and related supplies are considered supplies are not considered DME and are not covered under plans that exclude supplies.
A portable home model suction pump is a light-weight, compact, electric aspirator designed for upper respiratory, oral pharyngeal and tracheal suction for use in the home. Use of the device does not require technical or professional supervision. A stationary home model respiratory suction pump is an electric aspirator designed for oropharyngeal and tracheal suction.
A portable or stationary home model gastric suction pump is an electric aspirator designed to remove gastrointestinal secretions.
A closed system tracheal suction catheter is a type of suction catheter that is protected by an outer sheath. It is connected to the ventilator circuit of a person on mechanical ventilation and left in place. Suctioning is accomplished without disconnection from ventilation.
A tracheal suction catheter is a long, flexible catheter.
An oropharyngeal catheter is a short, rigid (usually) plastic catheter of durable construction.
Wound suction is provided with an integrated system of components. This system contains a pump and dressing sets. It does not include a separate collection canister, a defining component of Negative Pressure Wound Therapy (NPWT). Instead, exudate is retained in the dressing materials. Wound suction systems that do not contain all of the required components are not classified as wound suction systems.
A portable home model suction pump for use on wounds describes a suction pump for wounds which provides controlled subatmospheric pressure that is designed for use with dressings, without a canister.
An absorptive wound dressing for use with a portable home model suction pump describes an allowance for dressing sets which are used in conjunction with a stationary or portable suction pump but not used with a canister. Each of these absorptive wound dressings is used for a single, complete dressing change, and contains all necessary components, including but not limited to non-adherent porous dressing, drainage tubing, and an occlusive dressing which creates a seal around the wound site for maintaining subatmospheric pressure at the wound. These dressing sets are selected based upon wound size using the smallest size necessary to cover the wound. For multiple wounds located close together, a single large dressing must be used rather than multiple smaller dressing sets if it is possible to fit the wounds under a single larger dressing set.
A disposable wound suction including dressing and accessories describes a disposable wound suction device. Suction is developed through the use of any type of mechanism. This device includes all components, accessories and dressings.
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|HCPCS codes covered if selection criteria are met:|
|A4216||Sterile water, saline and/or dextrose, diluent/flush, 10 ml|
|A4217||Sterile water/saline, 500 ml|
|A4605||Tracheal suction catheter, closed system, each|
|A4624||Tracheal suction catheter, any type other than closed system, each|
|A4628||Oropharyngeal suction catheter, each|
|A4927||Gloves, non-sterile, per 100|
|A7000||Canister, disposable, used with suction pump, each|
|A7001||Canister, non-disposable, used with suction pump, each|
|A7002||Tubing, used with suction pump, each|
|A9272||Wound suction, disposable, including dressing, all accessories and components, any type, each|
|E0600||Respiratory suction pump, home model, portable or stationary, electric|
|E2000||Gastric suction pump, home model, portable or stationary, electric|
|K0743||Suction pump, home model, portable, for use on wounds|
|K0744||Absorptive wound dressing for use with suction pump, home model, portable, pad size 16 square inches or less|
|K0745||Absorptive wound dressing for use with suction pump, home model, portable, pad size more than 16 square inches but less than or equal to 48 square inches|
|K0746||Absorptive wound dressing for use with suction pump, home model, portable, pad size greater than 48 square inches|
|Other HCPCS codes related to the CPB:|
|A4481||Tracheostoma filter, any type, any size, each|
|A4623||Tracheostomy, inner cannula|
|A4629||Tracheostomy care kit for established tracheostomy|
|A7047||Oral interface used with respiratory suction pump, each|
|A7501 - A7527||Tracheostomy supplies|
|ICD-10 codes covered if selection criteria are met:|
|C03.0 - C06.9
C09.0 - C14.8
|Malignant neoplasm of gum, oral cavity and pharynx|
|D00.00 - D00.08||Carcinoma in situ of lip, oral cavity, and pharynx|
|D00.1||Carcinoma in situ of esophagus|
|D10.0 - D11.9
|Benign neoplasm of mouth, pharynx, oral cavity, major salivary glands and esophagus|
|J39.0 - J39.2||Other diseases of pharynx|
|R13.0 - R13.19||Aphagia and dysphagia|
|R40.0 - R40.4||Somnolence, stupor and coma|