E0484 Non-elec oscillatory pep dvcOscillatory positive expiratory pressure device, non-electric, any type, each
E0484 appears in 7 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, Blue Shield of California, Premera Blue Cross.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Chest Physiotherapy and Airway Clearance Devices (0067) | covered if criteria are met | 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 |
| 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 Rhode Island | Multifunction Home Ventilators PAYMENT POLICY | 2 | listed, no stance | May 15, 2024 | 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 | |
| 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 |
Prior authorization required or conditional in IN, MA, MS, NY, WV.
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.