`E0481` Intrpulmnry percuss vent sys

Intrapulmonary percussive ventilation system and related accessories

Medicare coverage: Non-covered by Medicare
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 0 units per day (clinical), rationale: CMS Policy
Outpatient hospital: max 0 units per day (clinical), rationale: CMS Policy
DME supplier: max 1 units per day (policy), rationale: Code Descriptor / CPT Instruction

Payer policies and prior authorization for E0481

42 of 43 payer prior-auth lists that name E0481 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas, Blue Shield of California Promise Health Plan, CarePlus Health Plans, Cigna, Humana, Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of Texas, Molina Healthcare of Utah, Passport by Molina Healthcare (Kentucky), UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Shield of California Promise Health Plan	Promise Health Plan Medi-Cal	CA	prior auth required		Sep 1, 2026	Medi-Cal Prior Authorization List
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Feb 6, 2012	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	May be delegated to eviCore for some clients	Feb 6, 2012	Master Precertification List (For Health Care Providers)
Cigna	Durable Medical Equipment	All	prior auth required	Experimental/investigational	Mar 7, 2026	Cigna Commercial Prior Authorization Procedure Code List: Durable Medical Equipment
Cigna	Durable Medical Equipment	All	prior auth required	Experimental/investigational	Mar 7, 2026	Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs
Blue Cross and Blue Shield of Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Jul 1, 2026	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana D-SNP (FL)	FL	prior auth required		Jan 1, 2027	1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
Humana	Humana D-SNP (IL)	IL	prior auth required		Jan 1, 2027	Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
Humana	Humana D-SNP (IN)	IN	prior auth required		Jan 1, 2027	*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
Humana	Humana D-SNP (MI)	MI	prior auth required		Jan 1, 2027	1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List
Humana	Humana D-SNP (SC)	SC	prior auth required		Jan 1, 2027	Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana Healthy Horizons	IN	prior auth required		Jan 1, 2027	1 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a
Humana	Humana Healthy Horizons	OK	prior auth required		Jan 1, 2027	Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana MA and D-SNP	All	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana Puerto Rico MA and Dual Medicare-Medicaid	PR	prior auth required		Nov 3, 2025	Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
Humana	Oak Street Health	All	prior auth required			Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Molina Complete Care (Virginia)	Medicaid	VA	prior auth required		Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of Idaho	Medicaid	ID	prior auth required		Jan 1, 2025	Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Jan 1, 2022	Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of Iowa	Medicaid	IA	prior auth required		Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Exchange	MI	prior auth required		Jul 1, 2021	Molina Healthcare of Michigan PA Matrix, effective 7/1/2021
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required		Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of Nevada	Medicaid	NV	prior auth required		Oct 1, 2022	Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of New Mexico	Medicaid	NM	prior auth required		Jul 1, 2026	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
Molina Healthcare of Ohio	Medicaid and MyCare Ohio (MMP) Medicaid	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Exchange	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Texas	STAR	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of Texas	STAR+PLUS	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19
Molina Healthcare of Texas	STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)	TX	prior auth required		Jul 1, 2026	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
Molina Healthcare of Texas	Exchange	TX	prior auth required		Sep 1, 2019	Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
Molina Healthcare of Utah	Medicaid	UT	prior auth required		Jan 1, 2025	Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required		Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
UnitedHealthcare Community Plan	Massachusetts OneCare	MA	prior auth under conditions	Cost over $1,000	Nov 1, 2025	Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025
UnitedHealthcare Community Plan	Massachusetts Senior Care Options (SCO)	MA	prior auth under conditions	Prior authorization is required only for a retail purchase or cumulative rental cost of more than	Nov 1, 2025	CPT® is a registered trademark of the American Medical Association. Prior authorization requirements for Massachusetts Senior Care Options Effective November 1, 2025
UnitedHealthcare Community Plan	Massachusetts Senior Care Options (SCO) and OneCare	MA	prior auth under conditions	Cost over $1,000	Oct 1, 2026	Prior authorization requirements for Massachusetts MA SCO OneCare Effective October 1, 2026
UnitedHealthcare Community Plan	Texas STAR Kids	TX	prior auth under conditions	Prior authorization is required only for codes listed with a retail purchase or a cumulative rental cost of more than $500.	Oct 1, 2017	Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki
UnitedHealthcare Community Plan	Texas STAR+PLUS	TX	prior auth required		Oct 1, 2017	Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p

Payer coverage policies that name E0481

E0481 appears in 17 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, Blue Shield of California, Cigna, Premera Blue Cross, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Chest Physiotherapy and Airway Clearance Devices (0067)	not covered	Mar 18, 2026	payer document
Aetna	Pulse Oximetry and Capnography for Home Use (0339)	listed, no stance (range E0455-E0484)	May 21, 2026	payer document
Anthem	Intrapulmonary Percussive Ventilation Devices (DME.00012)	unproven / investigational	May 14, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Oscillatory Devices For The Treatment Of Cystic Fibrosis And Other Respiratory Conditions	covered if criteria are met		payer document
Blue Cross Blue Shield of Massachusetts	Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions (120)	listed, no stance		payer document
Blue Shield of California	Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions (1.01.15)	listed, no stance		payer document
Cigna	Airway Clearance Devices in the Ambulatory Setting (0069)	not covered	Nov 9, 2025	payer document
Premera Blue Cross	Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions (1.01.539)	listed, no stance	Oct 13, 2025	payer document
UnitedHealthcare	Airway Clearance Devices (2026T0052OO)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Airway Clearance Devices (CS054.W)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Airway Clearance Devices (for Kansas Only) (CS054KS.03)	listed, no stance	Apr 1, 2026	payer document
UnitedHealthcare	Airway Clearance Devices (for Kentucky Only) (CS054KY.15)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Airway Clearance Devices (for Nebraska Only) (CS054NE.W)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Airway Clearance Devices (for New Mexico Only) (CS054NM.D)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Airway Clearance Devices (for Ohio Only) (CS054OH.D)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Airway Clearance Devices (for Pennsylvania Only) (CS054PA.V)	listed, no stance	Apr 1, 2026	payer document
UnitedHealthcare	Airway Clearance Devices (for Tennessee Only) (CS054TN.U)	listed, no stance	May 1, 2026	payer document

Recent prior-auth changes

Oct 1, 2026: PA removed, Oxford Health Plans
Jan 1, 2026: PA added, Molina Healthcare of Michigan
Jan 1, 2026: PA removed, Molina Healthcare of Michigan
Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan
Aug 1, 2025: conditions changed, UnitedHealthcare Community Plan
Jul 1, 2024: PA added, Molina Healthcare of Mississippi

Medicaid fee-for-service

Prior authorization required or conditional in CO, IL, IN, MD, NY, WY.

IL: $8736.00 (dme), effective Jan 1, 2026
MD: $1315.72 (dme), effective Apr 1, 2026
NY: $191.90 (dme), effective Jul 1, 2026
OH: $7500.00 (dme), effective Jan 1, 2024
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

E0481 Intrpulmnry percuss vent sys