Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Pneumatic Nebulizers
Policy Application
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.
A small volume, non-filtered nebulizer with compressor may be considered medical necessary for the administration for inhaled medications, as per The United States Food and Drug Administration (U.S. FDA) indications for
ANY
of the following conditions listed below. The medications for these conditions may include but are not limited to those listed.
- Pulmonary disease, including, but not limited to:
-
Chronic bronchitis,
or;
-
Chronic Obstructive Pulmonary Disease (COPD);
or;
-
Emphysema,
or;
-
Asthma,
or;
-
COVID-19 (Coronavirus Disease 2019)
;or
- The medications for these conditions may include but are not limited to those listed below:
-
Beta-adrenergics (albuterol)
;or
-
Isoproterenol
;or
-
Levalbuteral
;or
-
Metaproterenol
;or
-
Anticholinergics (ipratropium)
;or
-
Corticosteroids (budesonide)
;or
-
Cromolyn
;or
-
Formoterol (Perforomist)
;or
- Arformoterol (Brovana)
- Bronchiectasis
- Antibiotics such as Amikacin, Gentamycin, Tobramycin
- Persistent thick or tenacious secretions
- Croup
- Multi-drug resistant P. aeruginosa pneumonia failing to improve with IV therapy
-
Mycobacertium Avium Complex (MAC) with complex pulmonary disease not responsive to conventional three drug treatment of macrolide, rifampin and ethambutol.
- Amikacin liposome inhalation suspension (Arikayce),
A small volume, nonfiltered nebulizer with compressor may be considered medically necessary for the administration of inhaled medications
ONLY
when the medical necessity requirements for the medications, that are found in Medical Policy I-143 Inhalation Products for the Management of Cystic Fibrosis, have been met:
Small volume, nonfiltered nebulizers not meeting the criteria as indicated in this policy are considered not medically necessary.
Policy Application
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.
Procedure Codes
A4619 | A7003 | A7004 | A7005 | A7013 | A7014 | A7015 |
A7525 | E0570 | J3490 | J7605 | J7606 | J7608 | J7611 |
J7612 | J7613 | J7614 | J7626 | J7631 | J7644 | J7669 |
S0142 |
