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Nebulizers

Section: Durable Medical Equipment
Effective Date: July 01, 2019
Revised Date: June 12, 2019
Last Reviewed: January 22, 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 facemask or mouthpiece. 

Criteria

Pneumatic Nebulizers

A small volume, nonfiltered nebulizer with compressor may be considered medically necessary for the administration of ANY of the following medications: 

  • Beta-adrenergics (albuterol,isoproterenol, isoetharine, levalbuteral, metaproterenol), anticholinergics (ipratropium), corticosteroids (budesonide), and cromolyn for the management of chronic obstructive pulmonary diseases (COPD) (e.g., chronic bronchitis, emphysema, asthma, etc.); or
  • Antibiotics (Amikacin, or Gentamycin) for individuals with bronchiectasis; or
  • Acetylcysteine for individuals with persistent thick or tenacious secretions; or
  • Epinephrine for individuals with croup; or
  • Colistin for multi-drug resistant P. aeruginosa pneumonia failing to improve on IV therapy; or
  • Formoterol (Perforomist) or arformoterol (Brovana) for the management of COPD. 

A small volume, nonfiltered nebulizer with compressor may be considered medically necessary for the administration of the following medications ONLY when the medical necessity requirements for the medications, have been met: 

  • Antibiotics (Tobramycin) for individuals with cystic fibrosis (CF); or
  • Dornase alfa (Pulmozyme) for individuals with CF or primary ciliary dyskinesia; or
  • Aztreonam inhalation solution (Cayston) to persons with CF with Pseudomonas aeruginosa. 

All other uses of small volume, nonfiltered 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  J7639  J7644  J7669 
J7682  J7685  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
  • 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  J7682  J7685 

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, J7639, J7644, J7669, J7682, J7685, S0142

A15.0  A22.1  A37.01  A37.11  A37.81  A37.91  A48.1 
B20  B25.0  B44.0  B59  B77.81  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  J21.0  J21.1  J21.8 
J21.9  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  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 

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

B20  B59  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 

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  B44.0  B59  B77.81  E84.0  E84.11 
E84.19  E84.8  E84.9  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  J11.00  J11.08  J11.1  J11.2  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  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  J98.09 
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  Z43.0  Z93.0 

Covered Diagnosis Codes for A7013, A7014, A7016, E0574, J7682

A15.0  E84.0  E84.11  E84.19  E84.8  E84.9  J47.0 
J47.1  J47.9  Q33.4

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