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Clinical Policy Bulletin:
Suction Pumps
Number: 0503


Policy

Suction Pump:

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:

  1. Cancer or surgery of the throat or mouth; or
  2. Dysfunction of the swallowing muscles; or
  3. Tracheostomy; or
  4. Unconsciousness or obtunded state.

Aetna considers suction pumps experimental and investigational for all other indications because of insufficient evidence of effectiveness for other indications.

Supplies:

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:

  • Disposable or non-disposable canister used with suction pump
  • Oropharyngeal suction catheters
  • Tubing used with 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
787.2 Dysphagia
V44.0 Tracheostomy status


The above policy is based on the following references:
  1. NHIC, Corp. Suction pumps. Local Coverage Determination No. L11505. Contractor's Determination No. SUCP20070101. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised March 1, 2011.
  2. NHIC, Corp. Suction pumps. Local Coverage Article No. A25314. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdication A. Hingham, MA: NHIC; revised September 1, 2009.
  3. American Association for Respiratory Care (AARC). Suctioning of the patient in the home. AARC Clinical Practice Guidelines. Respir Care. 1999;44(1):91-98.
  4. Woollons S.  Ambulatory suction equipment for home use. Prof Nur. 1996;11(6):373-374, 376.
  5. Thompson L. Suctioning adults with an artificial airway: A systematic review. Systematic Review; 9. Adelaide, SA: Joanna Briggs Institute for Evidence Based Nursing and Midwifery; 2000.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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