LCD for Nebulizers (L33370)

Contractor Information

Contractor Name

CGS - Tennessee

Contract Number

17003

Contract Type

DME MAC

LCD Information

LCD ID

L33370

Original ICD-9 LCD ID

L27226

LCD Title

Nebulizers

Jurisdiction

Illinois
Indiana
Kentucky
Michigan
Minnesota
Ohio
Wisconsin

Original Effective Date

For services performed on or after 10/01/2015

Revision Effective Date

For services performed on or after 01/01/2016

Revision Ending Date

N/A

Retirement Date

N/A

Notice Period Start Date

N/A

Notice Period End Date

N/A

AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT only copyright 2002-2014 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association (“AHA”), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA.” Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company.

CMS National Coverage Policy

CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 200.2, 280.1

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee for Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.

For some items in this policy to be covered by Medicare, a written order prior to delivery (WOPD) is required. Refer to the DOCUMENTATION REQUIREMENTS section of this LCD and to the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article for information about WOPD prescription requirements.

A small volume nebulizer (A7003, A7004, A7005), related compressor (E0570) and FDA-approved inhalation solutions of the drugs listed below are covered when:

It is reasonable and necessary to administer albuterol (J7611, J7613), arformoterol (J7605), budesonide (J7626), cromolyn (J7631), formoterol (J7606), ipratropium (J7644), levalbuterol (J7612, J7614), or metaproterenol (J7669) for the management of obstructive pulmonary disease (Reference the Diagnosis Codes that Support Medical Necessity Group 8 Codes section for applicable diagnoses); or
It is reasonable and necessary to administer dornase alpha (J7639) to a beneficiary with cystic fibrosis (Reference the Diagnosis Codes that Support Medical Necessity Group 9 Codes section for applicable diagnoses); or
It is reasonable and necessary to administer tobramycin (J7682) to a beneficiary with cystic fibrosis or bronchiectasis (Reference the Diagnosis Codes that Support Medical Necessity Group 10 Codes section for applicable diagnoses); or
It is reasonable and necessary to administer pentamidine (J2545) to a beneficiary with HIV, pneumocystosis, or complications of organ transplants (Reference the Diagnosis Codes that Support Medical Necessity Group 4 Codes section for applicable diagnoses); or
It is reasonable and necessary to administer acetylcysteine (J7608) for persistent thick or tenacious pulmonary secretions (Reference the Diagnosis Codes that Support Medical Necessity Group 7 Codes section for applicable diagnoses).

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.

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.

A large volume nebulizer (A7007, A7017), related compressor (E0565 or E0572), and water or saline (A4217 or A7018) are covered when it is reasonable and necessary to deliver humidity to a beneficiary with thick, tenacious secretions, who has cystic fibrosis, bronchiectasis, a tracheostomy, or a tracheobronchial stent (Reference the Diagnosis Codes that Support Medical Necessity Group 5 Codes section for applicable diagnoses). Combination code E0585 will be covered for the same indications.

An E0565 or E0572 compressor and filtered nebulizer (A7006) are also covered when it is reasonable and necessary to administer pentamidine to beneficiaries with HIV, pneumocystosis, or complications of organ transplants (Reference the Diagnosis Codes that Support Medical Necessity Group 1 Codes section for applicable diagnoses).

A small volume ultrasonic nebulizer (E0574) and related accessories are reasonable and necessary to administer treprostinil inhalation solution only. Claims for code E0574 used with other inhalation solutions will be denied as not reasonable and necessary.

Treprostinil inhalation solution (J7686) and iloprost (Q4074) are covered when all of the following criteria 1-3 are met:

The beneficiary has a diagnosis of pulmonary artery hypertension (Reference the Diagnosis Codes that Support Medical Necessity Group 1 Codes section for applicable diagnoses); and
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
The beneficiary 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, anorexigens or congenital left to right shunts. If these conditions are present, the following criteria (a-d) must be met:
1. The pulmonary hypertension has progressed despite maximal medical and/or surgical treatment of the identified condition; and
2. The mean pulmonary artery pressure is > 25 mm Hg at rest or > 30 mm Hg with exertion; and
3. The beneficiary has significant symptoms from the pulmonary hypertension (i.e., severe dyspnea on exertion, and either fatigability, angina, or syncope); and
4. Treatment with oral calcium channel blocking agents has been tried and failed, or has been considered and ruled out

If the above criteria are not met, code E0574 and the related drug (J7686 for treprostinil) or code K0730 and the related drug (Q4074 for iloprost) will be denied as not reasonable and necessary.

A controlled dose inhalation drug delivery system (K0730) is covered when it is reasonable and necessary to deliver iloprost (Q4074) to beneficiaries with pulmonary hypertension only (Reference the Diagnosis Codes that Support Medical Necessity Group 11 Codes section for applicable diagnoses). Claims for code K0730 for use with other inhalation solutions will be denied as not reasonable and necessary.

A large volume ultrasonic nebulizer (E0575) offers no proven clinical advantage over a pneumatic compressor and nebulizer and will be denied as not reasonable and necessary.

ACCESSORIES:

Accessories are separately payable if the related aerosol compressor and the individual accessories are reasonable and necessary. The following table lists the compressor/generator, which is related to the accessories described. Other compressor/generator/accessory combinations are considered not reasonable and necessary.

Compressor/ GeneratorRelated Accessories

E0565A4619, A7006, A7007, A7010, A7012, A7013, A7014, A7015, A7017, A7525, E1372

E0570A7003, A7004, A7005, A7006, A7013, A7015, A7525

E0572A7006, A7014

E0574A7013, A7014, A7016

E0585A4619, A7006, A7010, A7012, A7013, A7014, A7015, A7525

K0730A7005

This array of accessories represents all possible combinations but it may not be appropriate to bill any or all of them for one device.

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 reasonable and necessary.

AccessoryUsual Maximum Replacement

A4619One/month

A7003Two/month

A7004Two/month (in addition to A7003)

A7005One/6 months

A7005One/3 months only with K0730

A7006One/month

A7007Two/month

A7010One unit (100 ft.)/2 months

A7012Two/month

A7013Two/month

A7014One/3 months

A7015One/month

A7016Two/year

A7017One/3 years

A7525One/month

E1372One/3 years

INHALATION DRUGS AND SOLUTIONS:

The following table represents the maximum milligrams/month of inhalation drugs that are reasonable and necessary for each nebulizer drug.

Inhalation Drugs and SolutionsMaximum Milligrams/Month

Acetylcysteine74 grams/month

Albuterol465 mg/month (See below for exception)

Albuterol/Ipratropium combination186 units/month

Arformoterol930 micrograms per month – 62 units per month

Budesonide62 units per month

Cromolyn sodium2480 mg/month – 248 units/month

Dornase alpha78 mg/month

Formoterol1240 micrograms per month – 62 units per month

Ipratropium bromide93 mg/month

Levalbuterol232.5 mg/month – 465 units/month (See below for exception)

Metaproterenol2800 mg/month – 280 units per month (See below for exception)

Pentamidine300 mg/month

Treprostinil31 units/month

Sterile saline or water, 10ml/unit (A4216, A4218)56 units/month

Distilled water, sterile water, or sterile saline in large volume nebulizer18 liters/month

When albuterol, levalbuterol, or metaproterenol are prescribed as rescue/supplemental medication for beneficiaries who are taking formoterol or arformoterol, the maximum milligrams/month that are reasonably billed are:

DrugMaximum Milligrams/Month

Albuterol78 mg/month

Albuterol/Ipratroprium combination31 units/month

Levalbuterol39 mg/month – 78 units/month

Metaproterenol470 mg/month – 47 units/month

Claims for more than these amounts of drugs will be denied as not reasonable and necessary.

When a "concentrated form" of an inhalation drug is covered, separate saline solution (A4216 or A4218 [metered dose]) used to dilute it will be separately reimbursed. Saline dispensed for the dilution of concentrated nebulizer drugs must be billed on the same claim as the drug(s) being diluted. If the unit dose form of the drug is dispensed, separate saline solution (A4216 or A4218 [metered dose]), will be denied as not reasonable and necessary. Water or saline in 500 or 1000 ml quantities (A4217 or A7018) are not appropriate for use by beneficiaries to dilute inhalation drugs and will therefore be denied as not reasonable and necessary if used for this purpose. These codes are only reasonable and necessary when used in a large volume nebulizer (A7007, A7017, or E0585).

Albuterol, levalbuterol, and metaproterenol are all short-acting bronchodilators with beta-adrenergic stimulatory effect. It is not reasonable and necessary for a beneficiary to use more than one of these at a time. The use of more than one of these drugs at the same time will be denied as not reasonable and necessary.

Albuterol, levalbuterol, or metaproterenol is covered if it is used as a rescue/supplemental medication in addition to the long-acting beta-adrenergic agonist drug, formoterol or arformoterol.

Formoterol and arformoterol are long-acting bronchodilators with beta-adrenergic stimulatory effect. It is not reasonable and necessary for a beneficiary to use more than one of these at a time. The use of more than one of these drugs at the same time will be denied as not reasonable and necessary.

Code J7620 describes the FDA-approved unit dose combination of albuterol base 2.5 mg and ipratropium bromide 0.5 mg in unit dose vials. The medical necessity for administering additional albuterol sulfate (J7611, J7613), levalbuterol (J7612, J7614) and/or ipratropium bromide (J7644) has not been established. Claims for J7611-J7614 and J7644 billed in addition to J7620 will be denied as not reasonable and necessary.

Charges for the drugs, diluent, and dispensing fees may only be billed by the entity that actually dispenses the drug to the Medicare beneficiary and that entity must be permitted under all applicable federal, state, and local laws and regulations to dispense drugs. Only entities licensed in the state where they are physically located may submit a claim for nebulizer drugs. Physicians may submit a claim for drugs if all of the following conditions are met: the physician is 1) enrolled as a DMEPOS supplier with the National Supplier Clearinghouse, and 2) dispensing the drug(s) to the Medicare beneficiary, and 3) authorized by the State to dispense drugs as part of the physician’s license. Claims submitted by entities not licensed to dispense drugs will be denied for lack of medical necessity.

REFILL REQUIREMENTS

For DMEPOS items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For DMEPOS products (A4619, A7003-A7017, A7525, all inhalation medications) that are supplied as refills to the original order, suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes/modifications to the order. Contact with the beneficiary or designee regarding refills must take place no sooner than 14 calendar days prior to the delivery/shipping date. For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product. This is regardless of which delivery method is utilized. (CMS’ Program Integrity Manual, Internet-Only Manual, CMS Pub. 100-08, Chapter 5, Section 5.2.6).

For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.

Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the ordering physicians that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not dispense more than a three (3)-month quantity at a time.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

Group 1 Paragraph:

The appearance of a code in this section does not necessarily indicate coverage.

EY - No physician or other licensed health care provider order for this item or service
GA - Waiver of liability statement issued as required by payer policy, individual case
GZ - Item or service expected to be denied as not reasonable and necessary
KO - Single drug unit dose formulation
KP - First drug of a multiple drug unit dose formulation
KQ - Second or subsequent drug of a multiple drug unit dose formulation
KX - Requirements specified in the medical policy have been met

HCPCS CODES:

EQUIPMENT

Group 1 Codes:

HCPCSDescription

E0565COMPRESSOR, AIR POWER SOURCE FOR EQUIPMENT WHICH IS NOT SELF- CONTAINED OR CYLINDER DRIVEN

E0570NEBULIZER, WITH COMPRESSOR

E0572AEROSOL COMPRESSOR, ADJUSTABLE PRESSURE, LIGHT DUTY FOR INTERMITTENT USE

E0574ULTRASONIC/ELECTRONIC AEROSOL GENERATOR WITH SMALL VOLUME NEBULIZER

E0575NEBULIZER, ULTRASONIC, LARGE VOLUME

E0585NEBULIZER, WITH COMPRESSOR AND HEATER

K0730CONTROLLED DOSE INHALATION DRUG DELIVERY SYSTEM

Group 2 Paragraph: ACCESSORIES

Group 2 Codes:

HCPCSDescription

A4619FACE TENT

A7003ADMINISTRATION SET, WITH SMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER, DISPOSABLE

A7004SMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER, DISPOSABLE

A7005ADMINISTRATION SET, WITH SMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER, NON-DISPOSABLE

A7006ADMINISTRATION SET, WITH SMALL VOLUME FILTERED PNEUMATIC NEBULIZER

A7007LARGE VOLUME NEBULIZER, DISPOSABLE, UNFILLED, USED WITH AEROSOL COMPRESSOR

A7008LARGE VOLUME NEBULIZER, DISPOSABLE, PREFILLED, USED WITH AEROSOL COMPRESSOR

A7009RESERVOIR BOTTLE, NON-DISPOSABLE, USED WITH LARGE VOLUME ULTRASONIC NEBULIZER

A7010CORRUGATED TUBING, DISPOSABLE, USED WITH LARGE VOLUME NEBULIZER, 100 FEET

A7012WATER COLLECTION DEVICE, USED WITH LARGE VOLUME NEBULIZER

A7013FILTER, DISPOSABLE, USED WITH AEROSOL COMPRESSOR OR ULTRASONIC GENERATOR

A7014FILTER, NONDISPOSABLE, USED WITH AEROSOL COMPRESSOR OR ULTRASONIC GENERATOR

A7015AEROSOL MASK, USED WITH DME NEBULIZER

A7016DOME AND MOUTHPIECE, USED WITH SMALL VOLUME ULTRASONIC NEBULIZER

A7017NEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, NOT USED WITH OXYGEN

A7525TRACHEOSTOMY MASK, EACH

E0580NEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER

E1372IMMERSION EXTERNAL HEATER FOR NEBULIZER

Group 3 Paragraph: INHALATION DRUGS AND SOLUTIONS

Group 3 Codes:

HCPCSDescription

A4216STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML

A4217STERILE WATER/SALINE, 500 ML

A4218STERILE SALINE OR WATER, METERED DOSE DISPENSER, 10 ML

A7018WATER, DISTILLED, USED WITH LARGE VOLUME NEBULIZER, 1000 ML

G0333PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS A BENEFICIARY

J2545PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MG

J7604ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM

J7605ARFORMOTEROL, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 15 MICROGRAMS

J7606FORMOTEROL FUMARATE, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 20 MICROGRAMS

J7607LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 0.5 MG

J7608ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM

J7609ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG

J7610ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 1 MG

J7611ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 1 MG

J7612LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 0.5 MG

J7613ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG

J7614LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG

J7615LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG

J7620ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME

J7622BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM

J7624BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM

J7626BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG

J7627BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG

J7628BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM

J7629BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM

J7631CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS

J7632CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS

J7634BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM

J7635ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM

J7636ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM

J7637DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM

J7638DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM

J7639DORNASE ALFA, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM

J7640FORMOTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 12 MICROGRAMS

J7641FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE, PER MILLIGRAM

J7642GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM

J7643GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM

J7644IPRATROPIUM BROMIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM

J7645IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM

J7647ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM

J7650ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM

J7657ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM

J7660ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM

J7667METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, CONCENTRATED FORM, PER 10 MILLIGRAMS

J7669METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS

J7670METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS

J7676PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MG

J7680TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM

J7681TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM

J7682TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, UNIT DOSE FORM, ADMINISTERED THROUGH DME, PER 300 MILLIGRAMS

J7683TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM

J7684TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM

J7685TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MILLIGRAMS

J7686TREPROSTINIL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 1.74 MG

J7699NOC DRUGS, INHALATION SOLUTION ADMINISTERED THROUGH DME

Q0513PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); PER 30 DAYS

Q0514PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); PER 90 DAYS

Q4074ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 20 MICROGRAMS

ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on “Coverage Indications, Limitations and/or Medical Necessity” for other coverage criteria and payment information.

For HCPCS codes A4619, E0565, E0572:

Group 1 Codes:

ICD-10 CodeDescription

A15.0Tuberculosis of lung

B20Human immunodeficiency virus [HIV] disease

B59Pneumocystosis

E84.0Cystic fibrosis with pulmonary manifestations

J39.8Other specified diseases of upper respiratory tract

J47.0Bronchiectasis with acute lower respiratory infection

J47.1Bronchiectasis with (acute) exacerbation

J47.9Bronchiectasis, uncomplicated

J98.09Other diseases of bronchus, not elsewhere classified

Q33.4Congenital bronchiectasis

T86.00Unspecified complication of bone marrow transplant

T86.01Bone marrow transplant rejection

T86.02Bone marrow transplant failure

T86.03Bone marrow transplant infection

T86.09Other complications of bone marrow transplant

T86.10Unspecified complication of kidney transplant

T86.11Kidney transplant rejection

T86.12Kidney transplant failure

T86.13Kidney transplant infection

T86.19Other complication of kidney transplant

T86.20Unspecified complication of heart transplant

T86.21Heart transplant rejection

T86.22Heart transplant failure

T86.23Heart transplant infection

T86.290Cardiac allograft vasculopathy

T86.298Other complications of heart transplant

T86.30Unspecified complication of heart-lung transplant

T86.31Heart-lung transplant rejection

T86.32Heart-lung transplant failure

T86.33Heart-lung transplant infection

T86.39Other complications of heart-lung transplant

T86.40Unspecified complication of liver transplant

T86.41Liver transplant rejection

T86.42Liver transplant failure

T86.43Liver transplant infection

T86.49Other complications of liver transplant

T86.5Complications of stem cell transplant

T86.810Lung transplant rejection

T86.811Lung transplant failure

T86.812Lung transplant infection

T86.818Other complications of lung transplant

T86.819Unspecified complication of lung transplant

T86.830Bone graft rejection

T86.831Bone graft failure

T86.832Bone graft infection

T86.838Other complications of bone graft

T86.839Unspecified complication of bone graft

T86.850Intestine transplant rejection

T86.851Intestine transplant failure

T86.852Intestine transplant infection

T86.858Other complications of intestine transplant

T86.859Unspecified complication of intestine transplant

T86.890Other transplanted tissue rejection

T86.891Other transplanted tissue failure

T86.892Other transplanted tissue infection

T86.898Other complications of other transplanted tissue

T86.899Unspecified complication of other transplanted tissue

T86.90Unspecified complication of unspecified transplanted organ and tissue

T86.91Unspecified transplanted organ and tissue rejection

T86.92Unspecified transplanted organ and tissue failure

T86.93Unspecified transplanted organ and tissue infection

T86.99Other complications of unspecified transplanted organ and tissue

Z43.0Encounter for attention to tracheostomy

Z93.0Tracheostomy status

Group 2 Paragraph: For HCPCS codes A7015, A7525:

Group 2 Codes:

ICD-10 CodeDescription

A15.0Tuberculosis of lung

A22.1Pulmonary anthrax

A37.01Whooping cough due to Bordetella pertussis with pneumonia

A37.11Whooping cough due to Bordetella parapertussis with pneumonia

A37.81Whooping cough due to other Bordetella species with pneumonia

A37.91Whooping cough, unspecified species with pneumonia

A48.1Legionnaires' disease

B20Human immunodeficiency virus [HIV] disease

B25.0Cytomegaloviral pneumonitis

B44.0Invasive pulmonary aspergillosis

B59Pneumocystosis

B77.81Ascariasis pneumonia

E84.0Cystic fibrosis with pulmonary manifestations

J09.X1Influenza due to identified novel influenza A virus with pneumonia

J09.X2Influenza due to identified novel influenza A virus with other respiratory manifestations

J09.X3Influenza due to identified novel influenza A virus with gastrointestinal manifestations

J09.X9Influenza due to identified novel influenza A virus with other manifestations

J10.00Influenza due to other identified influenza virus with unspecified type of pneumonia

J10.01Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia

J10.08Influenza due to other identified influenza virus with other specified pneumonia

J10.1Influenza due to other identified influenza virus with other respiratory manifestations

J10.2Influenza due to other identified influenza virus with gastrointestinal manifestations

J10.81Influenza due to other identified influenza virus with encephalopathy

J10.82Influenza due to other identified influenza virus with myocarditis

J10.83Influenza due to other identified influenza virus with otitis media

J10.89Influenza due to other identified influenza virus with other manifestations

J11.00Influenza due to unidentified influenza virus with unspecified type of pneumonia

J11.08Influenza due to unidentified influenza virus with specified pneumonia

J11.1Influenza due to unidentified influenza virus with other respiratory manifestations

J11.2Influenza due to unidentified influenza virus with gastrointestinal manifestations

J11.81Influenza due to unidentified influenza virus with encephalopathy

J11.82Influenza due to unidentified influenza virus with myocarditis

J11.83Influenza due to unidentified influenza virus with otitis media

J11.89Influenza due to unidentified influenza virus with other manifestations

J12.0Adenoviral pneumonia

J12.1Respiratory syncytial virus pneumonia

J12.2Parainfluenza virus pneumonia

J12.3Human metapneumovirus pneumonia

J12.81Pneumonia due to SARS-associated coronavirus

J12.89Other viral pneumonia

J12.9Viral pneumonia, unspecified

J13Pneumonia due to Streptococcus pneumoniae

J14Pneumonia due to Hemophilus influenzae

J15.0Pneumonia due to Klebsiella pneumoniae

J15.1Pneumonia due to Pseudomonas

J15.20Pneumonia due to staphylococcus, unspecified

J15.211Pneumonia due to Methicillin susceptible Staphylococcus aureus

J15.212Pneumonia due to Methicillin resistant Staphylococcus aureus

J15.29Pneumonia due to other staphylococcus

J15.3Pneumonia due to streptococcus, group B

J15.4Pneumonia due to other streptococci

J15.5Pneumonia due to Escherichia coli

J15.6Pneumonia due to other aerobic Gram-negative bacteria

J15.7Pneumonia due to Mycoplasma pneumoniae

J15.8Pneumonia due to other specified bacteria

J15.9Unspecified bacterial pneumonia

J16.0Chlamydial pneumonia

J16.8Pneumonia due to other specified infectious organisms

J18.0Bronchopneumonia, unspecified organism

J18.1Lobar pneumonia, unspecified organism

J18.8Other pneumonia, unspecified organism

J18.9Pneumonia, unspecified organism

J39.8Other specified diseases of upper respiratory tract

J40Bronchitis, not specified as acute or chronic

J41.0Simple chronic bronchitis

J41.1Mucopurulent chronic bronchitis

J41.8Mixed simple and mucopurulent chronic bronchitis

J42Unspecified chronic bronchitis

J43.0Unilateral pulmonary emphysema [MacLeod's syndrome]

J43.1Panlobular emphysema

J43.2Centrilobular emphysema

J43.8Other emphysema

J43.9Emphysema, unspecified

J44.0Chronic obstructive pulmonary disease with acute lower respiratory infection

J44.1Chronic obstructive pulmonary disease with (acute) exacerbation

J44.9Chronic obstructive pulmonary disease, unspecified

J45.20Mild intermittent asthma, uncomplicated

J45.21Mild intermittent asthma with (acute) exacerbation

J45.22Mild intermittent asthma with status asthmaticus

J45.30Mild persistent asthma, uncomplicated

J45.31Mild persistent asthma with (acute) exacerbation

J45.32Mild persistent asthma with status asthmaticus

J45.40Moderate persistent asthma, uncomplicated

J45.41Moderate persistent asthma with (acute) exacerbation

J45.42Moderate persistent asthma with status asthmaticus

J45.50Severe persistent asthma, uncomplicated

J45.51Severe persistent asthma with (acute) exacerbation

J45.52Severe persistent asthma with status asthmaticus

J45.901Unspecified asthma with (acute) exacerbation

J45.902Unspecified asthma with status asthmaticus

J45.909Unspecified asthma, uncomplicated

J45.990Exercise induced bronchospasm

J45.991Cough variant asthma

J45.998Other asthma

J47.0Bronchiectasis with acute lower respiratory infection

J47.1Bronchiectasis with (acute) exacerbation

J47.9Bronchiectasis, uncomplicated

J60Coalworker's pneumoconiosis

J61Pneumoconiosis due to asbestos and other mineral fibers

J62.0Pneumoconiosis due to talc dust

J62.8Pneumoconiosis due to other dust containing silica

J63.0Aluminosis (of lung)

J63.1Bauxite fibrosis (of lung)

J63.2Berylliosis

J63.3Graphite fibrosis (of lung)

J63.4Siderosis

J63.5Stannosis

J63.6Pneumoconiosis due to other specified inorganic dusts

J64Unspecified pneumoconiosis

J65Pneumoconiosis associated with tuberculosis

J66.0Byssinosis

J66.1Flax-dressers' disease

J66.2Cannabinosis

J66.8Airway disease due to other specific organic dusts

J67.0Farmer's lung

J67.1Bagassosis

J67.2Bird fancier's lung

J67.3Suberosis

J67.4Maltworker's lung

J67.5Mushroom-worker's lung

J67.6Maple-bark-stripper's lung

J67.7Air conditioner and humidifier lung

J67.8Hypersensitivity pneumonitis due to other organic dusts

J67.9Hypersensitivity pneumonitis due to unspecified organic dust

J68.0Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors

J68.1Pulmonary edema due to chemicals, gases, fumes and vapors

J68.2Upper respiratory inflammation due to chemicals, gases, fumes and vapors, not elsewhere classified

J68.3Other acute and subacute respiratory conditions due to chemicals, gases, fumes and vapors

J68.4Chronic respiratory conditions due to chemicals, gases, fumes and vapors

J68.8Other respiratory conditions due to chemicals, gases, fumes and vapors

J68.9Unspecified respiratory condition due to chemicals, gases, fumes and vapors

J69.0Pneumonitis due to inhalation of food and vomit

J69.1Pneumonitis due to inhalation of oils and essences

J69.8Pneumonitis due to inhalation of other solids and liquids

J70.0Acute pulmonary manifestations due to radiation

J70.1Chronic and other pulmonary manifestations due to radiation

J70.2Acute drug-induced interstitial lung disorders

J70.3Chronic drug-induced interstitial lung disorders

J70.4Drug-induced interstitial lung disorders, unspecified

J70.5Respiratory conditions due to smoke inhalation

J70.8Respiratory conditions due to other specified external agents

J70.9Respiratory conditions due to unspecified external agent

J98.09Other diseases of bronchus, not elsewhere classified

Q33.4Congenital bronchiectasis

T86.00Unspecified complication of bone marrow transplant

T86.01Bone marrow transplant rejection

T86.02Bone marrow transplant failure

T86.03Bone marrow transplant infection

T86.09Other complications of bone marrow transplant

T86.10Unspecified complication of kidney transplant

T86.11Kidney transplant rejection

T86.12Kidney transplant failure

T86.13Kidney transplant infection

T86.19Other complication of kidney transplant

T86.20Unspecified complication of heart transplant

T86.21Heart transplant rejection

T86.22Heart transplant failure

T86.23Heart transplant infection

T86.290Cardiac allograft vasculopathy

T86.298Other complications of heart transplant

T86.30Unspecified complication of heart-lung transplant

T86.31Heart-lung transplant rejection

T86.32Heart-lung transplant failure

T86.33Heart-lung transplant infection

T86.39Other complications of heart-lung transplant

T86.40Unspecified complication of liver transplant

T86.41Liver transplant rejection

T86.42Liver transplant failure

T86.43Liver transplant infection

T86.49Other complications of liver transplant

T86.5Complications of stem cell transplant

T86.810Lung transplant rejection

T86.811Lung transplant failure

T86.812Lung transplant infection

T86.818Other complications of lung transplant

T86.819Unspecified complication of lung transplant

T86.830Bone graft rejection

T86.831Bone graft failure

T86.832Bone graft infection

T86.838Other complications of bone graft

T86.839Unspecified complication of bone graft

T86.850Intestine transplant rejection

T86.851Intestine transplant failure

T86.852Intestine transplant infection

T86.858Other complications of intestine transplant

T86.859Unspecified complication of intestine transplant

T86.890Other transplanted tissue rejection

T86.891Other transplanted tissue failure

T86.892Other transplanted tissue infection

T86.898Other complications of other transplanted tissue

T86.899Unspecified complication of other transplanted tissue

T86.90Unspecified complication of unspecified transplanted organ and tissue

T86.91Unspecified transplanted organ and tissue rejection

T86.92Unspecified transplanted organ and tissue failure

T86.93Unspecified transplanted organ and tissue infection

T86.99Other complications of unspecified transplanted organ and tissue

Z43.0Encounter for attention to tracheostomy

Z93.0Tracheostomy status

Group 3 Paragraph: For HCPCS codes A7003, A7004, E0570:

Group 3 Codes: