Nebulizers

Section: Durable Medical Equipment
Effective Date: April 20, 2020
Revised Date: April 06, 2020
Last Reviewed: April 06, 2020

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 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,
    • Chronic Obstructive Pulmonary Disease (COPD)
    • Emphysema,
    • Asthma.
    • COVID-19
    • The medications for these conditions may include but are not limited to those listed below:
      • Beta-adrenergics (albuterol),
      • Isoproterenol,
      • Isoetharine,
      • Levalbuteral,
      • Metaproterenol,
      • Anticholinergics (ipratropium),
      • Corticosteroids (budesonide),
      • Cromolyn
      • 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

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 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

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.

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

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.

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 A37.01 A37.11 A37.81 A37.91 A48.1
B20 B25.0 B34.2 B44.0 B59 B77.81 B97.2
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
J12.89 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 B97.2 B97.21 B97.29 J12.81
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 B97.2
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 J12.89 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.

Links

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.