Medicare Part C Medical Coverage Policy
Origination: June 17, 2009
Review Date: October 20, 2021
Next Review: October 2023
***This policy applies to all Blue Medicare HMO, Blue Medicare PPO, Blue
Medicare Rx members, and members of any third-party Medicare plans
supported by Blue Cross NC through administrative or operational services. ***
Nebulizer medications are used to prevent and treat wheezing, difficulty breathing and
chest tightness caused by lung diseases such as asthma and chronic obstructive
pulmonary disease (COPD). They work by relaxing and opening air passages to the
lungs to make breathing easier.
Coverage will be provided for nebulizers when it is determined to be medically
necessary because the medical criteria and guidelines shown below are met.
Please refer to the member's individual Evidence of Coverage (EOC) for benefit
determination. Coverage will be approved according to the EOC limitations if the
criteria are met.
Coverage decisions will be made in accordance with:
? The Centers for Medicare & Medicaid Services (CMS) National Coverage
? General coverage guidelines included in Original Medicare manuals unless
superseded by operational policy letters or regulations; and
? Written coverage decisions of local Medicare carriers and intermediaries with
jurisdiction for claims in the geographic area in which services are covered.
Benefit payments are subject to contractual obligations of the Plan. If there is a conflict between the general
policy guidelines contained in the Medical Coverage Policy Manual and the terms of the member's particular
Evidence of Coverage (EOC), the EOC always governs the determination of benefits.
INDICATIONS FOR COVERAGE
PART B COVERAGE CRITERIA:
1. Preauthorization by the Plan may be required;
Medical Coverage Policy: Nebulizer Medications 2
2. FDA-approved inhalation solutions of the drugs listed below using a small
volume nebulizer and related compressor are covered when:
a) The administration of albuterol, arformoterol, budesonide, cromolyn,
formoterol, ipratropium, levalbuterol, metaproterenol, or revefenacin for the
management of obstructive pulmonary disease (ICD-10; J41.0-J70.9); or
b) The administration of dornase alpha to a member with cystic fibrosis (ICD-
10; E84.0); or
c) The administration of tobramycin to a member with cystic fibrosis or
bronchiectasis (ICD-10; E84.0), (ICD-10; J47.9), (ICD-10; J47.1), (ICD-10;
Q33.4) or (ICD-10; A15.0-A15.9); or
d) The administration of pentamidine to a members with HIV, (ICD-10; B20.),
pneumocystosis (ICD-10; B59), or complications of organ transplants (ICD-
10; T86.890; T86.891; T86.899); or
e) The administration of acetylcysteine for persistent thick or tenacious
pulmonary secretions (ICD-10; J12.0; J70.9); (ICD 10; R09.3).
3. A large volume nebulizer, related compressor, and water or saline are covered
when it is medically necessary to deliver humidity to a member with thick,
tenacious secretions who has cystic fibrosis, (ICD 10; R09.3), bronchiectasis
(ICD-10; J47.9), (ICD-10; J47.1), (ICD-10; A15.0) or (ICD-10; Q33.4), a
tracheostomy (ICD-10; Z93.0 or V55.0), or a tracheobronchial stent (ICD 10;
J39.8 and J98.09).
4. An E0565 or E0572 compressor and filtered nebulizer (A7006) are also
covered when it is reasonable and necessary to administer pentamidine to
members with HIV (ICD-10; B20), pneumocystosis (ICD 10; B59); or
complications of organ transplants (ICD 10; T86.90; T86.91; T86.92; T86.99)
and, (ICD 10; T86.890; T86.89; T86.899).
5. Trespostinil inhalation solution and Iloprost is covered when all the
following criteria1-3 below are met:
a) The member has a diagnosis of pulmonary artery hypertension,
(ICD-10; I27.0) or (ICD 10; I27.2; I27.89); and
b) The pulmonary hypertension is not secondary to pulmonary venous
hypertension (e.g., left sided atrial or ventricular disease, left sided
valvular heart disease, etc.) or disorders of the respiratory system
(e.g., chronic obstructive pulmonary disease, interstitial lung
disease, obstructive sleep apnea or other sleep disordered
breathing, alveolar hypoventilation disorders, etc.), and
Medical Coverage Policy: Nebulizer Medications 3
c) The member has primary pulmonary hypertension or pulmonary
hypertension which is secondary to one of the following conditions:
connective tissue disease, thromboembolic disease of the
pulmonary arteries, human immunodeficiency virus (HIV) infection,
cirrhosis, diet drugs, congenital left to right shunts, etc. If these
conditions are present, the following criteria (a-d) must be met:
i. The pulmonary hypertension has progressed despite maximal
medical and/or surgical treatment of the identified condition; and
ii. The mean pulmonary artery pressure is greater than 25 mm Hg
at rest or greater than 30 mm Hg with exertion; and
iii. The member has significant symptoms from the pulmonary
hypertension (i.e., severe dyspnea on exertion, and either
fatigability, angina, or syncope); and
iv. Treatment with oral calcium channel blocking agents has been
tried and failed, or has been considered and ruled out.
WHEN COVERAGE WILL NOT BE APPROVED UNDER PART B BENEFIT
A. When the above criteria are not met.
B. Aztreonam lysine is an inhalation solution that is indicated for members with cystic
fibrosis with chronic Pseudomonas aeruginosa infection. Medicare has
determined that the nebulizer that is FDA-approved for administration of
aztreonam lysine is not sufficiently durable to meet the requirements for coverage
under the DME benefit for that nebulizer, therefore aztreonam lysine inhalation
solution and related accessories will be denied as noncovered (no Medicare
C. Compounded inhalation solutions (J7604, J7607, J7609, J7610, J7615, J7622,
J7624, J7627, J7628, J7629, J7632, J7634, J7635, J7636, J7637, J7638, J7640,
J7641, J7642, J7643, J7645, J7647, J7650, J7657, J7660, J7667, J7670, J7676,
J7680, J7681, J7683, J7684, J7685, and compounded solutions billed with
J7699) will be denied as not reasonable and necessary.
NOTE: Code Q9977 Compounded Drug, Not Otherwise Classified, does not apply
to compounded nebulizer drugs.
D. A large volume ultrasonic nebulizer (E0575) offers no proven clinical advantage
over a pneumatic compressor and nebulizer and will be denied as not reasonable
E. A prefilled disposable large volume nebulizer (A7008) is considered a
convenience item and is noncovered.
PART D COVERAGE CRITERIA:
A. Preauthorization by the Plan is required;
What is the CPT code for nebulizer?code E0585 (Also covered) Large Volume Nebulizer . A7007, A7017 . and . Water or Saline . A4217, A7018 . Acetylcysteine (J7608) E0575 . ... If none of the drugs used with a nebulizer are covered, the compressor, the nebulizer, and other related accessories/supplies will be denied as not reasonable and necessary.
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