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LCD - Nebulizer

Coverage Summary:

  1. Written Order Prior to Delivery
  2. Equipment and supplies are not covered unless the drug is covered. See Coverage Detail below for specific coverage per diagnosis and prescribed drug.

Order Requirements:

  1. Patient's Name
  2. Specific description of ordered items including prescribed medication to be used in the device
  3. Prescribed settings
  4. Prescribed frequency of use
  5. Length of Medical Need
  6. Ordering Physician’s NPI
  7. Ordering physician’s legible signature (personally written or electronically signed by the physician, stamps are not accepted by insurance)
  8. Ordering physician’s legible signature date (personally written or electronically signed by the physician, stamps are not accepted by insurance)
  9. Start date of the order – if different than physician signature date.

Coverage Detail:

A small volume nebulizer (A7003, A7004, A7005), related compressor (E0570) and FDA-approved inhalation solutions of the drugs listed below are covered when:

Dx 491.0-508.9 (obstructive pulmonary disease) with drug:

  • albuterol (J7611, J7613)
  • arformoterol (J7605)
  • budesonide (J7626)
  • cromolyn (J7631)
  • formoterol (J7606)
  • ipratropium (J7644)
  • levalbuterol (J7612, J7614)
  • metaproterenol (J7669)

Dx 277.02 (cystic fibrosis) with drug:

  • dornase alpha (J7639)

Dx 011.50-011.56 (cystic fibrosis or bronchiectasis) with drug:

  • tobramycin (J7682)

Dx 042, 163.3, 996.80-996.89 (HIV, pneumocystosis, or complications with organ transplant) with drug:

  • pentamidine (J2545)

Dx 480.0-508.9, 786.4 (persistent thick or tenacious pulmonary secretions) with drug:

  • acetylcysteine (J7608)

Ultrasonic Nebulizer (E0574) and related supplies are ONLY covered to administer treprostinil inhalation solution ONLY

Treprostinil inhalation solution (J7686) and iloprost (Q4074) are covered when ALL 1-3 are met:

  1. Dx 011.50-011.56, 042, 136.3, 277.02, 494.0, 494.1, 519.19, 748.61, 996.80-996.89, V44.0, V55.0 and;
  2. Pulmonary hypertension is NOT secondary to pulmonary venous hypertension (ie, left sided atrial or ventricular disease, left sided valvular heart disease) or disorders of respiratory system (ie, COPD, interstitial lung disease, OSA, or other sleep disordered breathing, alveolar hypoventilation disorders, etc) and;
  3. HAS primary pulmonary hypertension or pulmonary hypertension which is secondary to one of the following conditions: connective tissue disease, thromboembolic disease of the pulmonary arteries, human immunodeficiency virus (HIV) infection, cirrhosis, anorexigens or congenital left to right shunts. If these conditions are present, the following criteria (a-d) must be met:

  • The pulmonary hypertension has progressed despite maximal medical and/or surgical treatment of the identified condition; and

  • The mean pulmonary artery pressure is > 25 mm Hg at rest or > 30 mm Hg with exertion; and

  • The beneficiary has significant symptoms from the pulmonary hypertension (i.e., severe dyspnea on exertion, and either fatigability, angina, or syncope); and

  • Treatment with oral calcium channel blocking agents has been tried and failed, or has been considered and ruled out