Aetna considers home model 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 suction pumps experimental and investigational for all other indications because of insufficient evidence of effectiveness for other indications.
Aetna considers tracheal suction catheters medically necessary supplies for suction pumps. 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.
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.Background
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.
|CPT Codes / HCPCS Codes / ICD-9 Codes|
|HCPCS codes covered if selection criteria are met:|
|A4216||Sterile water, saline and/or dextrose, diluent/flush, 10 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|
|E0600||Respiratory suction pump, home model, portable or stationary, electric|
|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-9 codes covered if selection criteria are met:|
|143.0 - 149.9||Malignant neoplasm of gum, floor of mouth, other and unspecified parts of mouth, oropharynx, nasopharynx, hypopharynx, and other and ill-defined sites within the lip, oral cavity, and pharynx|
|210.0 - 211.0||Benign neoplasm of lip, oral cavity, pharynx, and esophagus|
|230.0||Carcinoma in situ of lip, oral cavity, and pharynx|
|230.1||Carcinoma in situ of esophagus|
|478.20 - 478.29||Other diseases of pharynx, not elsewhere classified|
|780.01 - 780.09||Alteration of consciousness|