Nebulizers

Policy ID: E-32-021

Section: Durable Medical Equipment

Effective Date: July 01, 2019

Revised Date: July 26, 2022

Revision Effective Date: September 05, 2022

Last Reviewed: July 21, 2022

Applies To: Commercial and Medicaid Expansion

Description

Nebulizers, pneumatic or ultrasonic, are devices which use either compressed gas or high-frequency electric oscillations to aerosolize liquid medication into a fine mist for inhalation into the lower-respiratory tract. The medications are delivered either continuously or intermittently via a face mask or mouthpiece.

Criteria

Pneumatic Nebulizers

A small volume, non-filtered nebulizer with compressor may be considered medical necessary for the administration for inhaled medications, as per The U.S. Food and Drug Administration (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
- Acetylcysteine
Croup
- Epinephrine
Multi-drug resistant P. aeruginosa pneumonia failing to improve with IV therapy
- Colistin
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.

Procedure Codes

A4619

A7003

A7004

A7005

A7013

A7014

A7015

A7525

E0570

J3490

J7605

J7606

J7608

J7611

J7612

J7613

J7614

J7626

J7631

J7644

J7669

S0142

A small volume, filtered nebulizer with compressor may be considered medically necessary for the administration of pentamidine for individuals with ANY of the following conditions:

Human immunodeficiency virus (HIV); or
Post-organ transplantation with complications; or
Pneumocystosis.

Small volume filtered nebulizers not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

A7006

A7013

A7014

E0565

E0570

E0572

J2545

A large volume nebulizer, with compressor, or a nebulizer with compressor and heater, may be considered medically necessary to deliver humidity to a person with thick, tenacious secretions, with ANY of the following indications:

Bronchiectasis; or
Cystic Fibrosis (CF); or
Tracheobronchial stent; or
Tracheostomy

A non-disposable reservoir bottle when used with large volume nebulizers is considered not medically necessary.

A prefilled disposable large volume nebulizer is non-covered.

An unfilled disposable large volume nebulizer is non-covered.

Large volume nebulizers, with compressor, or a nebulizer with compressor and heat not meeting the criteria as indicated in this policy is/are considered not medically necessary.

Procedure Codes

A4619

A7007

A7008

A7009

A7010

A7012

A7013

A7014

A7015

A7017

A7525

A7526

E0565

E0572

E0585

E1372

Ultrasonic Nebulizers

Ultrasonic nebulizers may be considered medically necessary for delivery of tobramycin (Tobi) for individuals with CF ONLY when the medical necessity requirements for the medication have been met AND when ALL of the following indications are met:

The individual meets the criteria for a standard nebulizer; and
The primary care physician and specialist indicate that the individual has been compliant with other nebulizer and medication therapy; and
The use of a standard nebulizer has failed to control the individual’s disease and prevent the individual from utilizing the hospital or emergency room.

Ultrasonic nebulizers not meeting the criteria as indicated in this policy is/are considered not medically necessary.

Procedure Codes

A7013

A7014

A7016

E0574

A large volume ultrasonic nebulizer has no proven clinical advantage over a pneumatic compressor and nebulizer and is considered not medically necessary.

Procedure Codes

E0575

Accessories may be considered medically necessary when the nebulizer, compressor, and medications are medically necessary.

The following table lists the usual maximum frequency of replacement for accessories. Claims for more than the usual maximum replacement amount are considered not medically necessary:

Accessory

Usual Maximum Replacement

A4619

1 every month

A7003

2 every month

A7004

2 every month-in addition to A7003

A7005

1 every 6 months

A7006

1 every month

A7010

1 unit (100 ft.) every 2 months

A7012

2 every month

A7013

2 every month

A7014

1 every 3 months

A7015

1 every month

A7016

2 every year

A7017

1 every 3 years

A7525

1 every month

E1372

1 every 3 years

Diagnosis Codes

Covered Diagnosis Codes for A4619, A7003, A7004, A7005, A7013, A7014, A7015, A7525, E0570, J3490, J7605, J7606, J7608, J7611, J7612, J7613, J7614, J7626, J7631, J7644, J7669, S0142

A15.0

A22.1

A31.0

A31.2

A37.01

A37.11

A37.81

A37.91

A48.1

B20

B25.0

B34.2

B44.0

B59

B77.81

B97.21

B97.29

E84.0

E84.11

E84.19

E84.8

E84.9

J05.0

J09.X1

J09.X2

J09.X3

J09.X9

J10.1

J10.2

J10.00

J10.01

J10.08

J10.81

J10.82

J10.83

J10.89

J11.1

J11.2

J11.00

J11.08

J11.81

J11.82

J11.83

J11.89

J12.0

J12.1

J12.2

J12.3

J12.9

J12.81

J12.82

J12.89

J13

J14

J15.0

J15.1

J15.3

J15.4

J15.5

J15.6

J15.7

J15.8

J15.9

J15.20

J15.29

J15.211

J15.212

J16.0

J16.8

J18.0

J18.1

J18.8

J18.9

J20.8

J21.0

J21.1

J21.8

J21.9

J22

J40

J41.0

J41.1

J41.8

J42

J43.0

J43.1

J43.2

J43.8

J43.9

J44.0

J44.1

J44.9

J45.20

J45.21

J45.22

J45.30

J45.31

J45.32

J45.40

J45.41

J45.42

J45.50

J45.51

J45.52

J45.901

J45.902

J45.909

J45.990

J45.991

J45.998

J47.0

J47.1

J47.9

J60

J61

J62.0

J62.8

J63.0

J63.1

J63.2

J63.3

J63.4

J63.5

J63.6

J64

J65

J66.0

J66.1

J66.2

J66.8

J67.0

J67.1

J67.2

J67.3

J67.4

J67.5

J67.6

J67.7

J67.8

J67.9

J68.0

J68.1

J68.2

J68.3

J68.4

J68.8

J68.9

J69.0

J69.1

J69.8

J70.0

J70.1

J70.2

J70.3

J70.4

J70.5

J70.8

J70.9

J80

J98.8

Q33.4

T86.5

T86.00

T86.01

T86.02

T86.03

T86.09

T86.10

T86.11

T86.12

T86.13

T86.19

T86.20

T86.21

T86.22

T86.23

T86.30

T86.31

T86.32

T86.33

T86.39

T86.40

T86.41

T86.42

T86.43

T86.49

T86.90

T86.91

T86.92

T86.93

T86.99

T86.290

T86.298

T86.810

T86.811

T86.812

T86.818

T86.819

T86.830

T86.831

T86.832

T86.838

T86.839

T86.850

T86.851

T86.852

T86.858

T86.859

T86.890

T86.891

T86.892

T86.898

T86.899

U07.1

Covered Diagnosis Codes for A7006, A7013, A7014, E0565, E0570, E0572, J2545

B20

B34.2

B59

B97.21

B97.29

J12.81

J12.82

J12.89

J20.8

J22

J40

J80

J98.8

T86.5

T86.00

T86.01

T86.02

T86.03

T86.09

T86.10

T86.11

T86.12

T86.13

T86.19

T86.20

T86.21

T86.22

T86.23

T86.30

T86.31

T86.32

T86.33

T86.39

T86.40

T86.41

T86.42

T86.43

T86.49

T86.90

T86.91

T86.92

T86.93

T86.99

T86.290

T86.298

T86.810

T86.811

T86.812

T86.818

T86.819

T86.830

T86.831

T86.832

T86.838

T86.839

T86.850

T86.851

T86.852

T86.858

T86.859

T86.890

T86.891

T86.892

T86.898

T86.899

U07.1

Covered Diagnosis Codes for A4619, A7010, A7012, A7013, A7014,A7015, A7017, A7525, A7526, E0565, E0572, E0585, E1372

A15.0

A22.1

A37.01

A37.11

A37.81

A37.91

A48.1

B20

B25.0

B34.2

B44.0

B59

B77.81

B97.21

B97.29

E84.0

J09.X1

J09.X2

J09.X3

J09.X9

J10.1

J10.2

J10.00

J10.01

J10.08

J10.81

J10.82

J10.83

J10.89

J11.1

J11.2

J11.00

J11.08

J11.81

J11.82

J11.83

J11.89

J12.0

J12.1

J12.2

J12.3

J12.9

J12.81

J12.82

J12.89

J13

J14

J15.0

J15.1

J15.3

J15.4

J15.5

J15.6

J15.7

J15.8

J15.9

J15.20

J15.29

J15.211

J15.212

J16.0

J16.8

J18.0

J18.1

J18.8

J18.9

J20.8

J22

J39.8

J40

J41.0

J41.1

J41.8

J42

J43.0

J43.1

J43.2

J43.8

J43.9

J44.0

J44.1

J44.9

J45.20

J45.21

J45.22

J45.30

J45.31

J45.32

J45.40

J45.41

J45.42

J45.50

J45.51

J45.52

J45.901

J45.902

J45.909

J45.990

J45.991

J45.998

J47.0

J47.1

J47.9

J60

J61

J62.0

J62.8

J63.0

J63.1

J63.2

J63.3

J63.4

J63.5

J63.6

J64

J65

J66.0

J66.1

J66.2

J66.8

J67.0

J67.1

J67.2

J67.3

J67.4

J67.5

J67.6

J67.7

J67.8

J67.9

J68.0

J68.1

J68.2

J68.3

J68.4

J68.8

J68.9

J69.0

J69.1

J69.8

J70.0

J70.1

J70.2

J70.3

J70.4

J70.5

J70.8

J70.9

J80

J98.09

J98.8

Q33.4

T86.5

T86.00

T86.01

T86.02

T86.03

T86.09

T86.10

T86.11

T86.12

T86.13

T86.19

T86.20

T86.21

T86.22

T86.23

T86.30

T86.31

T86.32

T86.33

T86.39

T86.40

T86.41

T86.42

T86.43

T86.49

T86.90

T86.91

T86.92

T86.93

T86.99

T86.290

T86.298

T86.810

T86.811

T86.812

T86.818

T86.819

T86.830

T86.831

T86.832

T86.838

T86.839

T86.850

T86.851

T86.852

T86.858

T86.859

T86.890

T86.891

T86.892

T86.898

T86.899

U07.1

Z43.0

Z93.0

Covered Diagnosis Codes for A7013, A7014, A7016, E0574

A15.0

E84.0

J47.0

J47.1

J47.9

Q33.4

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Annual Review
Internal Medical Policy Committee 4-6-2020 Adding COVID 19 diagnosis codes for coverage . Procedure codes J7639, J7682, and J7685 removed and new policy Inhalation Products for the Management of Cystic Fibrosis created, added diagnosis codes E84.11, E84.19, E84.8 and E84.9.

Internal Medical Policy Committee 1-19-2021 Coding update added diagnosis code J12.82

Internal Medical Policy Committee 5-20-2021 Revision-Removed the medication Isoetharine.

Internal Medical Policy Committee 5-24-2022 Annual Review-no changes in criteria.

Internal Medical Policy Committee 7-21-2022 Revision- Effective September 05, 2022

Added clarifying statements
Added diagnosis code: Z93.0

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: E-32-020

Section: Durable Medical Equipment

Effective Date: July 01, 2019

Revised Date: May 04, 2021

Revision Effective Date: July 05, 2021

Last Reviewed: May 24, 2022

Archived Date: September 04, 2022

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Pneumatic Nebulizers

A small volume, non-filtered nebulizer with compressor may be considered medical necessary for the administration for inhaled medications, as per 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
- Acetylcysteine
Croup
- Epinephrine
Multi-drug resistant P. aeruginosa pneumonia failing to improve with IV therapy
- Colistin
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),

All other uses of small volume, non filtered nebulizer with compressor are considered not medically necessary.

Procedure Codes

A4619

A7003

A7004

A7005

A7013

A7014

A7015

A7525

E0570

J3490

J7605

J7606

J7608

J7611

J7612

J7613

J7614

J7626

J7631

J7644

J7669

S0142

A small volume, filtered nebulizer with compressor may be considered medically necessary for the administration of pentamidine for individuals with ANY of the following conditions:

Human immunodeficiency virus (HIV); or
Post-organ transplantation with complications; or
Pneumocystosis.

All other uses of small volume, filtered nebulizer with compressor are considered not medically necessary.

Procedure Codes

A7006

A7013

A7014

E0565

E0570

E0572

J2545

Bronchiectasis; or
Cystic Fibrosis (CF); or
Tracheobronchial stent; or
Tracheostomy

A non-disposable reservoir bottle when used with large volume nebulizers is considered not medically necessary.

A prefilled disposable large volume nebulizer is non-covered.

An unfilled disposable large volume nebulizer is non-covered.

All other uses of a large volume nebulizer, with compressor, or a nebulizer with compressor and heater are considered not medically necessary.

Procedure Codes

A4619

A7007

A7008

A7009

A7010

A7012

A7013

A7014

A7015

A7017

A7525

A7526

E0565

E0572

E0585

E1372

Ultrasonic Nebulizers

The individual meets the criteria for a standard nebulizer; and
The primary care physician and specialist indicate that the individual has been compliant with other nebulizer and medication therapy; and
The use of a standard nebulizer has failed to control the individual’s disease and prevent the individual from utilizing the hospital or emergency room.

All other uses of ultrasonic nebulizers are considered not medically necessary.

Procedure Codes

A7013

A7014

A7016

E0574

A large volume ultrasonic nebulizer has no proven clinical advantage over a pneumatic compressor and nebulizer and is considered not medically necessary.

Procedure Codes

E0575

Accessories may be considered medically necessary when the nebulizer, compressor, and medications are medically necessary.

The following table lists the usual maximum frequency of replacement for accessories. Claims for more than the usual maximum replacement amount are considered not medically necessary:

Accessory

Usual Maximum Replacement

A4619

1 every month

A7003

2 every month

A7004

2 every month-in addition to A7003

A7005

1 every 6 months

A7006

1 every month

A7010

1 unit (100 ft.) every 2 months

A7012

2 every month

A7013

2 every month

A7014

1 every 3 months

A7015

1 every month

A7016

2 every year

A7017

1 every 3 years

A7525

1 every month

E1372

1 every 3 years

Diagnosis Codes

Covered Diagnosis Codes for A4619, A7003, A7004, A7005, A7013, A7014, A7015, A7525, E0570, J3490, J7605, J7606, J7608,J7611, J7612, J7613, J7614, J7626, J7631, J7644, J7669, S0142

A15.0

A22.1

A31.0

A31.2

A37.01

A37.11

A37.81

A37.91

A48.1

B20

B25.0

B34.2

B44.0

B59

B77.81

B97.21

B97.29

E84.0

E84.11

E84.19

E84.8

E84.9

J05.0

J09.X1

J09.X2

J09.X3

J09.X9

J10.1

J10.2

J10.00

J10.01

J10.08

J10.81

J10.82

J10.83

J10.89

J11.1

J11.2

J11.00

J11.08

J11.81

J11.82

J11.83

J11.89

J12.0

J12.1

J12.2

J12.3

J12.9

J12.81

J12.82

J12.89

J13

J14

J15.0

J15.1

J15.3

J15.4

J15.5

J15.6

J15.7

J15.8

J15.9

J15.20

J15.29

J15.211

J15.212

J16.0

J16.8

J18.0

J18.1

J18.8

J18.9

J20.8

J21.0

J21.1

J21.8

J21.9

J22

J40

J41.0

J41.1

J41.8

J42

J43.0

J43.1

J43.2

J43.8

J43.9

J44.0

J44.1

J44.9

J45.20

J45.21

J45.22

J45.30

J45.31

J45.32

J45.40

J45.41

J45.42

J45.50

J45.51

J45.52

J45.901

J45.902

J45.909

J45.990

J45.991

J45.998

J47.0

J47.1

J47.9

J60

J61

J62.0

J62.8

J63.0

J63.1

J63.2

J63.3

J63.4

J63.5

J63.6

J64

J65

J66.0

J66.1

J66.2

J66.8

J67.0

J67.1

J67.2

J67.3

J67.4

J67.5

J67.6

J67.7

J67.8

J67.9

J68.0

J68.1

J68.2

J68.3

J68.4

J68.8

J68.9

J69.0

J69.1

J69.8

J70.0

J70.1

J70.2

J70.3

J70.4

J70.5

J70.8

J70.9

J80

J98.8

Q33.4

T86.5

T86.00

T86.01

T86.02

T86.03

T86.09

T86.10

T86.11

T86.12

T86.13

T86.19

T86.20

T86.21

T86.22

T86.23

T86.30

T86.31

T86.32

T86.33

T86.39

T86.40

T86.41

T86.42

T86.43

T86.49

T86.90

T86.91

T86.92

T86.93

T86.99

T86.290

T86.298

T86.810

T86.811

T86.812

T86.818

T86.819

T86.830

T86.831

T86.832

T86.838

T86.839

T86.850

T86.851

T86.852

T86.858

T86.859

T86.890

T86.891

T86.892

T86.898

T86.899

U07.1

Covered Diagnosis Codes for A7006, A7013, A7014, E0565, E0570, E0572, J2545

B20

B34.2

B59

B97.21

B97.29

J12.81

J12.82

J12.89

J20.8

J22

J40

J80

J98.8

T86.5

T86.00

T86.01

T86.02

T86.03

T86.09

T86.10

T86.11

T86.12

T86.13

T86.19

T86.20

T86.21

T86.22

T86.23

T86.30

T86.31

T86.32

T86.33

T86.39

T86.40

T86.41

T86.42

T86.43

T86.49

T86.90

T86.91

T86.92

T86.93

T86.99

T86.290

T86.298

T86.810

T86.811

T86.812

T86.818

T86.819

T86.830

T86.831

T86.832

T86.838

T86.839

T86.850

T86.851

T86.852

T86.858

T86.859

T86.890

T86.891

T86.892

T86.898

T86.899

U07.1

Covered Diagnosis Codes for A4619, A7010, A7012, A7013, A7014,A7015, A7017, A7525, A7526, E0565, E0572, E0585, E1372

A15.0

A22.1

A37.01

A37.11

A37.81

A37.91

A48.1

B20

B25.0

B34.2

B44.0

B59

B77.81

B97.21

B97.29

E84.0

J09.X1

J09.X2

J09.X3

J09.X9

J10.1

J10.2

J10.00

J10.01

J10.08

J10.81

J10.82

J10.83

J10.89

J11.1

J11.2

J11.00

J11.08

J11.81

J11.82

J11.83

J11.89

J12.0

J12.1

J12.2

J12.3

J12.9

J12.81

J12.82

J12.89

J13

J14

J15.0

J15.1

J15.3

J15.4

J15.5

J15.6

J15.7

J15.8

J15.9

J15.20

J15.29

J15.211

J15.212

J16.0

J16.8

J18.0

J18.1

J18.8

J18.9

J20.8

J22

J39.8

J40

J41.0

J41.1

J41.8

J42

J43.0

J43.1

J43.2

J43.8

J43.9

J44.0

J44.1

J44.9

J45.20

J45.21

J45.22

J45.30

J45.31

J45.32

J45.40

J45.41

J45.42

J45.50

J45.51

J45.52

J45.901

J45.902

J45.909

J45.990

J45.991

J45.998

J47.0

J47.1

J47.9

J60

J61

J62.0

J62.8

J63.0

J63.1

J63.2

J63.3

J63.4

J63.5

J63.6

J64

J65

J66.0

J66.1

J66.2

J66.8

J67.0

J67.1

J67.2

J67.3

J67.4

J67.5

J67.6

J67.7

J67.8

J67.9

J68.0

J68.1

J68.2

J68.3

J68.4

J68.8

J68.9

J69.0

J69.1

J69.8

J70.0

J70.1

J70.2

J70.3

J70.4

J70.5

J70.8

J70.9

J80

J98.09

J98.8

Q33.4

T86.5

T86.00

T86.01

T86.02

T86.03

T86.09

T86.10

T86.11

T86.12

T86.13

T86.19

T86.20

T86.21

T86.22

T86.23

T86.30

T86.31

T86.32

T86.33

T86.39

T86.40

T86.41

T86.42

T86.43

T86.49

T86.90

T86.91

T86.92

T86.93

T86.99

T86.290

T86.298

T86.810

T86.811

T86.812

T86.818

T86.819

T86.830

T86.831

T86.832

T86.838

T86.839

T86.850

T86.851

T86.852

T86.858

T86.859

T86.890

T86.891

T86.892

T86.898

T86.899

U07.1

Z43.0

Covered Diagnosis Codes for A7013, A7014, A7016, E0574

A15.0

E84.0

J47.0

J47.1

J47.9

Q33.4

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-19-2021 Coding update added diagnosis code J12.82

Internal Medical Policy Committee 5-20-2021 Revision-Removed the medication Isoetharine.

Internal Medical Policy Committee 5-24-2022 Annual Review-no changes in criteria.

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