Suction Pump/Breast Pump/Pneumatic Compression Devices

Suction Pump, Home Model, Portable

A portable home model suction pump is a lightweight compact, electric aspirator designed for upper respiratory oral pharyngotracheal suction for use in the home. Use of device does not require technical or professional supervision.

Benefits are provided for the following:

• Patients who have difficulty raising and clearing secretions secondary to:
  • Surgery for cancer of the throat;
• Dysfunction of the swallowing muscles;
• Unconsciousness or obtunded state;
• Tracheostomy

Breast Pump, All Types

Covered for electric breast pumps for mothers who have:

• Premature babies.
• Multiple births.
• Babies with congenital anomalies that cause inability to suck or nurse correctly.

All other rentals for electric breast pump are not covered.

Vaporizer, Room Type

Not covered.

Postural Drainage Board

Covered if patient has chronic pulmonary condition.

Trapeze Bars (AKA Patient Helper), Attached to Bed, with Grab Bar

Coverage criteria:

• Trapeze bar is covered when the patient needs the device to sit up due to respiratory condition, to change body position for other medical reasons, or to get in or out of bed.
• Benefits are provided only if patient is bed-confined.

Continuous Passive Motion Exercise Device

Benefits for continuous passive motion devices (CPMD) for additional procedures other than those listed will be considered on an individual case basis with documentation of meeting medical criteria for coverage.
CPMD includes exercise software supplies required (i.e.; lamb's wool padding, straps, etc.)

For Total Knee Replacement (E0935):

CPMD are eligible for coverage for total knee replacement as long as the device was started on the patient within two days after the surgery. In addition, coverage for use of the device is limited to a six-week period following discharge from the hospital after the surgery.

CPM device may be covered for post-operative care for the following surgeries:

• Open reduction and internal fixation for tibia plateau fracture
• Knee ligament reconstructive surgery
• Quadriceplasty
• Manipulation and osteotomy around the knee, distal femur or proximal tibia
• Autologous Chondrocyte Transplant (ACT)

For Shoulder Indications (E1399):

Benefits may be provided for CPMD for six weeks after the following shoulder surgeries:

• Arthroplasty of shoulder
• Adhesive capsulitis surgery
• Rotator cuff repair

Other uses may be considered on an individual case basis with documentation of medical necessity.
Claims for use of the device for longer than a six-week period must be reviewed for medical necessity.

Gravity-Assisted Traction Device, Any Type

Not covered.

Cervical Head Harness/Halter

Included in global fee for traction.

Pelvic Belt/Harness/Boot

Included in global fee for traction.