HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
E-32-015
Topic:
Nebulizers
Section:
Durable Medical Equipment
Effective Date:
October 1, 2017
Issued Date:
February 18, 2019
Last Revision Date:
February 2019
Annual Review:
February 2019
 
 

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.

Policy Position

 

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, Gentamycin, or Tobramycin) for individuals with cystic fibrosis (CF) or bronchiectasis; or
  • Dornase  alfa (Pulmozyme) for individuals with CF or primary ciliary dyskinesia ; 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
  • Aztreonam inhalation solution (Cayston) to persons with CF with Pseudomonas aeruginosa; or
  • Formoterol (Perforomist) or arformoterol (Brovana) for the management of COPD.

A4619

A7003

A7004

A7005

A7013

A7014

A7015

A7525

E0570

J7605

J7606

J7608

J7611

J7612

J7613

J7614

J7626

J7631

J7639

J7644

J7669

J7682

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.

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 for the above pneumatic nebulizers are considered not medically necessary.

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 who meet the criteria for a standard nebulizer 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.
 

A7013

A7014

A7016

E0574

J7682

 

 




A large volume ultrasonic nebulizer has no proven clinical advantage over a pneumatic compressor and nebulizer and will be denied as not medically necessary.

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 will be denied as 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

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME.

 


Related Policies

Refer to Medical Policy I-18, Pharmacologic Treatment of Pulmonary Arterial Hypertension, for additional information. 

Refer to Medical Policy E-19, Oxygen for additional information on nebulizers/regulators.   

Refer to Medical Policy E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME) for additional information.  

 


Covered Diagnosis Codes for A4619, A7003, A7004, A7005, A7013, A7014, A7015, A7525, E0570, J7605, J7606, J7608, J7611, J7612, J7613, J7614, J7626, J7631, J7639, J7644, J7669, J7682, 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

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

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

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

J47.0

J47.1

J47.9

Q33.4

 

 



Place of Service: Outpatient

The use of nebulizers is typically an outpatient service which is only eligible for coverage as an inpatient service in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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