E-32-026

HIGHMARK MEDICARE ADVANTAGE MEDICAL POLICY - PENNSYLVANIA

Medical Policy:

E-32-026

Topic:

Nebulizers

Section:

Durable Medical Equipment

Effective Date:

June 5, 2022

Issued Date:

August 8, 2022

Last Revision Date:

July 2022

Nebulization of inhalation solutions is accomplished by two (2) types of devices. Pneumatic compressor nebulizers achieve nebulization of liquid by means of air flow. Ultrasonic or electronic nebulizers produce nebulization of liquid by means of a vibrating mechanism.

Policy Position

To view specific LCD and NCD information, as well as other CMS sources, please refer to the LINKS section at the bottom of this policy page.

Equipment

A9270	E0565	E0570	E0572	E0574	E0575	E0585
K0730

Accessories

A4619	A7003	A7004	A7005	A7006	A7007	A7008
A7009	A7010	A7012	A7013	A7014	A7015	A7016
A7017	A7525	A9999	E0580	E1372

Inhalation Drugs and Solutions

A4216	A4217	A4218	A7018	G0333	J2545	J7604
J7605	J7606	J7607	J7608	J7609	J7610	J7611
J7612	J7613	J7614	J7615	J7620	J7622	J7624
J7626	J7627	J7628	J7629	J7631	J7632	J7634
J7635	J7636	J7637	J7638	J7639	J7640	J7641
J7642	J7643	J7644	J7645	J7647	J7650	J7657
J7660	J7667	J7669	J7670	J7676	J7677	J7680
J7681	J7682	J7683	J7684	J7685	J7686	J7699
Q0513	Q0514	Q4074

Covered Diagnosis Codes for Procedure Codes A4619, E0565, and E0572

A15.0	B20	B59	E84.0	J39.8	J47.0	J47.1
J47.9	J98.09	Q33.4	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	T86.290	T86.298	T86.30	T86.31
T86.32	T86.33	T86.39	T86.40	T86.41	T86.42	T86.43
T86.49	T86.5	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	T86.90	T86.91	T86.92	T86.93	T86.99	Z43.0
Z93.0

Covered Diagnosis Codes for Procedure Codes A7015 and A7525

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	J10.00	J10.01	J10.08	J10.1
J10.2	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	J12.81	J12.89	J12.9	J13
J14	J15.0	J15.1	J15.20	J15.211	J15.212	J15.29
J15.3	J15.4	J15.5	J15.6	J15.7	J15.8	J15.9
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	T86.00	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	T86.290	T86.298	T86.30
T86.31	T86.32	T86.33	T86.39	T86.40	T86.41	T86.42
T86.43	T86.49	T86.5	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	T86.90	T86.91	T86.92	T86.93	T86.99
Z43.0	Z93.0

Covered Diagnosis Codes for Procedure Codes A7003, A7004, and E0570

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	J10.00	J10.01	J10.08	J10.1
J10.2	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	J12.81	J12.89	J12.9	J13
J14	J15.0	J15.1	J15.20	J15.211	J15.212	J15.29
J15.3	J15.4	J15.5	J15.6	J15.7	J15.8	J15.9
J16.0	J16.8	J18.0	J18.1	J18.8	J18.9	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	T86.00	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	T86.290	T86.298	T86.30	T86.31	T86.32
T86.33	T86.39	T86.40	T86.41	T86.42	T86.43	T86.49
T86.5	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
T86.90	T86.91	T86.92	T86.93	T86.99

Covered Diagnosis Codes for Procedure Codes A7006 and J2545

B20	B59	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	T86.290	T86.298	T86.30	T86.31	T86.32
T86.33	T86.39	T86.40	T86.41	T86.42	T86.43	T86.49
T86.5	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
T86.90	T86.91	T86.92	T86.93	T86.99

Covered Diagnosis Codes for Procedure Codes A4217, A7007, A7010, A7012, A7017, A7018, E0585, and E1372

A15.0	E84.0	J39.8	J47.0	J47.1	J47.9	J98.09
Q33.4	Z43.0	Z93.0

Covered Diagnosis Codes for Procedure Code A4216

B20	B59	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	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	T86.290	T86.298	T86.30	T86.31
T86.32	T86.33	T86.39	T86.40	T86.41	T86.42	T86.43
T86.49	T86.5	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	T86.90	T86.91	T86.92	T86.93	T86.99

Covered Diagnosis Codes for Procedure Code J7608

A22.1	A37.01	A37.11	A37.81	A37.91	A48.1	B25.0
B44.0	B77.81	E84.0	J09.X1	J09.X2	J09.X3	J09.X9
J10.00	J10.01	J10.08	J10.1	J10.2	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
J12.81	J12.89	J12.9	J13	J14	J15.0	J15.1
J15.20	J15.211	J15.212	J15.29	J15.3	J15.4	J15.5
J15.6	J15.7	J15.8	J15.9	J16.0	J16.8	J18.0
J18.1	J18.8	J18.9	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

Covered Diagnosis Codes for Procedure Codes J7605, J7606, J7611, J7612, J7613, J7614 J7620, J7626, J7631, J7644, J7669, and J7677

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

Covered Diagnosis Code for Procedure Code J7639

E84.0

Covered Diagnosis Codes for Procedure Code J7682

A15.0

E84.0

J47.0

J47.1

J47.9

Q33.4

Covered Diagnosis Codes for Procedure Codes A7016, E0574, and J7686

I27.0

I27.20

I27.21

I27.23

I27.83

I27.89

Covered Diagnosis Codes for Procedure Code A7005

A15.0	A22.1	A37.01	A37.11	A37.81	A37.91	A48.1
B20	B25.0	B44.0	B59	B77.81	E84.0	I27.0
I27.20	I27.21	I27.23	I27.24	I27.29	I27.83	I27.89
J09.X1	J09.X2	J09.X3	J09.X9	J10.00	J10.01	J10.08
J10.1	J10.2	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	J12.81	J12.89	J12.9
J13	J14	J15.0	J15.1	J15.20	J15.211	J15.212
J15.29	J15.3	J15.4	J15.5	J15.6	J15.7	J15.8
J15.9	J16.0	J16.8	J18.0	J18.1	J18.8	J18.9
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	T86.00	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	T86.290	T86.298	T86.30	T86.31
T86.32	T86.33	T86.39	T86.40	T86.41	T86.42	T86.43
T86.49	T86.5	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	T86.90	T86.91	T86.92	T86.93	T86.99

Covered Diagnosis Codes for Procedure Codes A7013 and A7014

A15.0	A22.1	A37.01	A37.11	A37.81	A37.91	A48.1
B20	B25.0	B44.0	B59	B77.81	E84.0	I27.0
I27.20	I27.21	I27.23	I27.24	I27.29	I27.83	I27.89
J09.X1	J09.X2	J09.X3	J09.X9	J10.00	J10.01	J10.08
J10.1	J10.2	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	J12.81	J12.89	J12.9
J13	J14	J15.0	J15.1	J15.20	J15.211	J15.212
J15.29	J15.3	J15.4	J15.5	J15.6	J15.7	J15.8
J15.9	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	T86.00	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	T86.290	T86.298
T86.30	T86.31	T86.32	T86.33	T86.39	T86.40	T86.41
T86.42	T86.43	T86.49	T86.5	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	T86.90	T86.91	T86.92	T86.93
T86.99	Z43.0	Z93.0

Covered Diagnosis Codes for Procedure Codes K0730 and Q4074

I27.0

I27.20

I27.21

I27.83

I27.89

Related Policies

Refer to Medicare Advantage medical policy E-19 Oxygen and Oxygen Equipment for additional information.

Refer to Medicare Advantage medical policy E-74 Suction Pumps for additional information.

Refer to Highmark Reimbursement Policy Bulletin RP-003 Drug Wastage and Convenience Kits for additional information.

Refer to Medicare Advantage medical policy Z-99 Standard Documentation Requirements for All Claims Submitted to Durable Medical Equipment Medicare Administrative Contracts for additional information.

The policy position applies to all Medicare Advantage lines of business

Links

Link to Provider Resource Center for the Medical Policy Update

05/2016, Criteria Revised for Speech Generating Devices

CMS Links

CMS Website

Article Links

Article Link

NCD Links

NCD 200.2 Link

NCD 280.1 Link

LCD Links

LCD Link

References

Noridian Healthcare Solutions, LLC/CGS Administrators, LLC, LCD L33370. Revised 06/05/2022 (R9).
Noridian Healthcare Solutions, LLC/CGS Administrators, LLC, LCA A52466. Revised 06/05/2022 (R15).
CMS Internet Only Manual (IOM), Pub. 100-03, National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 200.2. Effective 09/10/2007.
CMS Internet Only Manual (IOM), Pub. 100-03, National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 280.1. Effective 05/05/2005.

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.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.