All order forms MUST be signed by the physician AND accompanied by: Face-to-Face Medical Recordsdocumen�ng the beneficiary was evaluated and treated for a condi�on that supports the need for the Afflovest.

Frequency of Use

Airway Clearance Therapy Tried & Failed.

Standard (5-20 Hz for 30 minute treatments twice per day)Custom:

CPT (Manual or Percussor)Hu� Coughing

Oscillating PEPBreathing Techniques

Hypertonic Saline Mucomyst(Notes must document if prescribed for secretion mobilization)Suctioning

Check all reasons why the above therapy failed, is contraindicated, or inappropriate.

Sizing Chart

Cannot Tolerate positioning / Hand CPT

For Bronchiectasis patients, please check Yes or No to the following question:Has there been a CT scan con�rming Bronchiectasis diagnosis?In addition, the following medical history in the past year must be documented in the patient’s progress notes.

Physical limitations of caregiver

For Cystic Fibrosis or Neuromuscular patients, the following must be documented in the patient’sprogress notes. Please attach records with RX.

Documentation supporting diagnosis

Yes No If “Yes” please include copy of CT scan.

Tried and failed a lesser airway clearance technique indicated above.

3 or more exacerbations, i.e., lung infections, requiring antibiotics, documented at least 3 separate times

Daily productive cough for at least 6 continuous months

XXS: 18” - 23” XS: 23” - 29” S: 29” - 35”L: 41” - 48” XL: 48” - 55” XXL: 55” - 65”

M: 35” - 41”

OR

Caregiver unable to perform adequate CPTGastroesophageal re�ux (GERD)

Too fragile for hand CPTCognitive LevelSevere arthritis, osteoporosisUnable to form mouth seal

Did not mobilize secretionsInsu�cient expiratory forceResistance to therapyArti�cial airway

Other

Hz for minute treatments time(s) per day.

Chest:Stomach:

Chest

Stomach

MRKT - 062REV/CF - 6/21

Patient Name:Date of Birth: Height: ft.Supporting Diagnosis:ICD Code:Insurance 1:

Discharge Date:Weight: lbs.

Primary Care Physician:

Room #:

Or # of Months:Length of Need: Lifetime

ID:Insurance 2: ID:

ICD Code:

in.

Place of Service:Facility Name:

Home Facility

PROVIDER’S ORDER FOR AFFLOVEST

KEENE MEDICALPRODUCTS, LLC.

MEDICALSALES

HOMERENTAL

HOME CARE IS OUR BUSINESS

KEENE MEDICAL PRODUCTS

“Bringing Healthcare Home Since 1975.”

5 Landing Road, Enfield, NH 03748Phone: (855) 622-5556 Fax: (855) 722-5556

I, the undersigned, certify that the above prescribed equipment and/or supplies are reasonable and medicallynecessary as part of the treatment of this patient. The need and medical necessity for the above listed

equipment and/or supplies are documented in the patient’s medical record.

Provider’s Signature:

Provider’s Name:Provider’s Medicaid Provider #:

Order & Signature Date:

NPI #:(Signature Stamps Not Allowed)

A�oVest HFCWO Therapy (HCPCS E0483)

Medicare approved ICD-10 Codes for A�oVest HFCWO Therapy (HCPCS E0483)

Medicare Requirements for Bronchiectasis:1. CT Scan con�rming diagnosis of bronchiectasis.AND2. Daily productive cough for at least 6 continuous months.ORFrequent (i.e. more than twice a year) exacerbations requiring antibiotic therapy.AND3. Documentation (chart notes) of another treatment tried to mobilize secretions and clearly indicatingthe other technique or device has failed.ICD-10 Code

Medicare Requirements for Other Respiratory, Cystic Fibrosis and Neuromuscular Conditions:Provider’s order that includes: A�oVest prescription, qualifying DX, chart notes to support the DX, andwell-documented failure of standard treatments to adequately mobilize retained secretions.

DescriptionJ47.0 Bronchiectasis with acute lower respiratory infection

ICD-10 Code Description ICD-10 Code DescriptionJ98.6 Disorders of diaphragmE84.0 Cystic �brosis with pulmonary manifestationsE84.9 Cystic �brosis, unspeci�edA15.0 Tuberculosis of lungB91 Sequelae of poliomyeletisD81.810 Biotinidase de�ciencyD84.1 Defects in the complement systemG12.0 Infantile spinal muscular atrophy, type I

(Werdnig-Ho�man)

G12.1 Other inherited spinal muscular atrophyG12.20 Motor neuron disease, unspeci�edG12.21 Amyotrophic lateral sclerosisG12.22 Progressive bulbar palsyG12.23 Primary lateral sclerosisG12.24 Familial motor neuron diseaseG12.25 Progressive spinal muscle atrophyG12.29 Other motor neuron diseaseG12.8 Other spinal muscular atrophies and related

syndromes

G12.9 Spinal muscular atrophy, unspeci�edG14 Postpolio syndromeG35 Multiple sclerosisG71.00 Muscular dystrophy, unspeci�edG71.01 Duchenne or Becker muscular dystrophyG71.02 Facioscapulohumeral muscular dystrophyG71.09 Other speci�ed muscular dystrophiesG71.11 Myotonic muscular dystrophyG71.12 Myotonia congenita

G71.13 Myotonic chondrodystrophyG71.14 Drug induced myotoniaG71.19 Other speci�ed myotonic disordersG71.2G71.21

Congenital myopathiesNemaline myopathy

G71.220 X-linked myotubular myopathyG71.228 Other centronuclear myopathyG71.29G71.3

Other congenital myopathyMtiochondrial myopathy, not elsewhereclassi�ed

G71.8 Other primary disorders of musclesG72.0 Drug-induced myopathyG72.1 Alcoholic myopathyG72.2 Myopathy due to other toxic agentsG72.89 Other speci�ed myopathiesG73.7 Myopathy in diseases classi�ed elsewhereG82.50 Quadriplegia, unspeci�edG82.51 Quadriplegia, C1 - C4 completeG82.52 Quadriplegia, C1 - C4 incompleteG82.53 Quadriplegia, C5 - C7 completeG82.54 Quadriplegia, C5 - C7 incompleteM33.02 Juvenile dermatomyositis with myopathyM33.12 Other dermatomyositis with myopathyM33.22 Polymyositis with myopathyM33.92 Dermatopolymyositis, unspeci�ed with

myopathy

M34.82 Systemic sclerosis with myopathyM35.03 Sicca syndrome with myopathy

J47.1 Bronchiectasis with (acute) exacerbationJ47.9 Bronchiectasis, uncomplicatedQ33.4 Congenital bronchiectasis