Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Nebulizers and Inhalation Solutions

Policy #:05.00.15p

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

PNEUMATIC NEBULIZERS
A small-volume, nonfiltered nebulizer (Healthcare Common Procedure Coding System [HCPCS] codes A7003, A7004, or A7005) with compressor (HCPCS code E0570) is considered medically necessary and, therefore, covered when used for the administration of any of the following medications:
  • Albuterol for individuals with asthma/obstructive pulmonary disease when a metered dose inhaler (MDI) with a spacer device was considered inappropriate or was insufficient for the administration of the medication
  • Budesonide, cromolyn, ipratropium, levalbuterol, metaproterenol, formoterol, or arformoterol for individuals with asthma/obstructive pulmonary disease
  • Tobramycin for individuals with cystic fibrosis (CF) or bronchiectasis
  • Dornase alpha for individuals with CF
  • Acetylcysteine for individuals with persistent thick or tenacious secretions
  • Pentamidine for individuals with any of the following conditions:
    • Human immunodeficiency virus (HIV)
    • Post-organ transplantation with complications
    • Pneumocystosis

A small-volume, filtered nebulizer (HCPCS code A7006) with compressor (HCPCS codes E0565 or E0572) is considered medically necessary and, therefore, covered for the administration of pentamidine to an individual with any of the following conditions:
  • HIV
  • Post-organ transplantation with complications
  • Pneumocystosis

A large-volume unfilled nebulizer (HCPCS codes A7007 or A7017) with compressor (HCPCS codes E0565 or E0572) or a nebulizer with compressor and heater (HCPCS code E0585) is considered medically necessary and, therefore, covered when both of the following criteria are met:
  • There is clinical presentation of at least one of the following:
    • Bronchiectasis
    • CF
    • Tracheobronchial stent
    • Tracheostomy
  • Humidity is required for tenacious secretions

If the medical necessity criteria for one of the small-volume or large-volume nebulizers listed above are met, the individual can obtain either a standard or a portable nebulizer. A portable nebulizer can be battery-operated or connected to an alternate power source (e.g., cigarette lighter).

All other uses for pneumatic nebulizers are considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

SMALL-VOLUME ULTRASONIC NEBULIZER AND CONTROLLED-DOSE INHALATION DRUG-DELIVERY SYSTEM
A small-volume ultrasonic nebulizer (HCPCS code E0574) for the administration of treprostinil inhalation solution or a controlled-dose inhalation drug-delivery system (HCPCS code K0730) for the administration of Iloprost are considered medically necessary and, therefore, covered for individuals who meet all of the following criteria:
  • The individual has a diagnosis of pulmonary artery hypertension that is not secondary to pulmonary venous hypertension (e.g., left-sided atrial or ventricular disease, left-sided valvular heart disease) 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).
  • The individual has primary pulmonary hypertension or pulmonary hypertension that is secondary to conditions that include, but are not limited to, the following: connective tissue disease, thromboembolic disease of the pulmonary arteries, HIV infection, cirrhosis, anorexigens (ie, diet drugs), and congenital left-to-right shunts. If these conditions are present, all of the following criteria must be met:
    • The pulmonary hypertension has progressed despite maximal medical and/or surgical treatment of the identified condition.
    • The mean pulmonary artery pressure is greater than 25 mmHg at rest or greater than 30 mmHg with exertion.
    • The individual has significant symptoms from the pulmonary hypertension (ie, severe dyspnea on exertion, and fatigability, angina, or syncope).
    • Treatment with oral calcium channel blocking agents has been tried and failed or has been considered and ruled out.

The use of small-volume ultrasonic nebulizers (HCPCS code E0574) for the delivery of any medication other than treprostinil inhalation solution, or that does not meet the medical necessity criteria, is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the treatment of illness or injury.

The use of the controlled-dose inhalation drug-delivery system (HCPCS code K0730) for the delivery of any medication other than Iloprost inhalation solution, or that does not meet the medical necessity criteria, is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the treatment of illness or injury.

ACCESSORIES FOR PNEUMATIC NEBULIZERS
Accessories for pneumatic nebulizers are separately reimbursable if the related aerosol compressor is considered medically necessary and the accessories are used in accordance with the time frames specified below.

The following accessories have a maximum replacement of one per month:
  • Face tent (HCPCS code A4619)
  • Administration set, with a small-volume filtered pneumatic nebulizer (HCPCS code A7006)
  • Aerosol mask, used with a DME nebulizer (HCPCS code A7015)
  • Tracheostomy mask (HCPCS code A7525)

The following accessories have a maximum replacement of two per month:
  • Administration set, with a small-volume nonfiltered pneumatic nebulizer, disposable (HCPCS code A7003)
  • Small-volume, nonfiltered pneumatic nebulizer, disposable (HCPCS code A7004), in addition to administration set, with small-volume, nonfiltered pneumatic nebulizer, disposable
  • Water collection device, used with large-volume nebulizer (HCPCS code A7012)
  • Filter, disposable, used with aerosol compressor (HCPCS code A7013)
  • Large-volume nebulizer, disposable, unfilled, used with aerosol compressor (HCPCS code A7007)

The following accessory has a maximum replacement of one unit (100 feet) per two months:
  • Corrugated tubing, disposable, used with large-volume nebulizer, 100 feet (HCPCS code A7010)

The following accessories have a maximum replacement of one per three months:
  • Administration set, with small-volume nonfiltered pneumatic nebulizer, nondisposable (HCPCS code A7005) only when used with controlled-dose inhalation drug-delivery system (HCPCS code K0730)
  • Filter, nondisposable, used with aerosol compressor or ultrasonic generator (HCPCS code A7014)

The following accessory has a maximum replacement of one per six months:
  • Administration set, with small-volume nonfiltered pneumatic nebulizer, nondisposable (HCPCS code A7005)

The following accessories have a maximum replacement of one per three years:
  • Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with oxygen (HCPCS code A7017)
  • Immersion external heater for nebulizer (HCPCS code E1372)

Kits and concentrates used to clean respiratory equipment are considered not medically necessary and, therefore, not covered.

ACCESSORIES FOR ULTRASONIC NEBULIZER
The following accessory has a maximum replacement of two per year:
  • Dome and mouthpiece, used for small-volume ultrasonic nebulizer (HCPCS code A7016)

ACCESSORIES FOR CONTROLLED-DOSE INHALATION DRUG-DELIVERY SYSTEM
The following accessory has a maximum replacement of one every 6 months:
  • Administration set, with small-volume nonfiltered pneumatic nebulizer, nondisposable (HCPCS code A7005)

NOT MEDICALLY NECESSARY

COMPOUNDED INHALATION SOLUTIONS
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) are considered not medically necessary and, therefore, not covered because commercially manufactured products are available.

NOT COVERED

NEBULIZATION DEVICES AND ACCESSORIES
A prefilled disposable large-volume nebulizer (HCPCS code A7008) is considered a convenience item and, therefore, not covered. It is not covered in accordance with the Company's definition of durable medical equipment. However, a disposable, unfilled nebulizer (HCPCS codes A7007, A7017, or E0585) that can be filled with water or saline by the individual or a caregiver is an acceptable alternative and considered medically necessary and, therefore, covered if the medical necessity criteria listed above for a large-volume nebulizer with compressor are met.

A large-volume nebulizer, related compressor or generator, and water or saline when used predominantly to provide room humidification are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis or treatment of illness or injury.

A duplicate small-volume or large-volume nebulizer (e.g., for use when traveling, for an additional residence, work, school) is not covered by the Company because it is a benefit contract exclusion. Therefore, it is not eligible for reimbursement consideration. Additionally, technological advancements or newly released upgrades to equipment, when the original equipment still functions properly and/or there are no significant changes in the individual's condition, are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis or treatment of illness or injury. Refer to the policy addressing the repair and replacement of durable medical equipment (DME) for more information.

A large-volume ultrasonic nebulizer (HCPCS code E0575) is considered a device that has features of a medical nature that are not required by the individual's condition, and is, therefore, not covered. It is not covered in accordance with the Company's definition of durable medical equipment.

A reservoir bottle, nondisposable (HCPCS code A7009), used with a large-volume ultrasonic nebulizer is equipment for a device that has features of a medical nature that are not required by the individual's condition, and is, therefore, not covered. It is not covered in accordance with the Company's definition of durable medical equipment.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier, and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, nebulizers and their accessories are covered under the medical benefits of the Company's products when the medical necessity criteria listed in the medical policy are met. However, nebulizers and their accessories that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved numerous nebulizer devices.

Description

Nebulizers are devices used to quickly convert liquid medication (e.g., bronchodilators, steroids) into a fine mist or aerosol for inhalation into the lower-respiratory tract. The medications are delivered either continuously or intermittently via a facemask or mouthpiece. Nebulizers are commonly used by individuals with chronic obstructive pulmonary disease (COPD), asthma, bronchiectasis, bronchiolitis, and cystic fibrosis (CF).

While metered-dose inhalers (MDIs) are the most common form of delivery for aerosol medications, nebulizers are indicated when the medication is only available as a solution, or if a high dose is required. Nebulizers are especially effective when treating infants, young children, individuals with impaired cognition, the acutely ill, and others who cannot master the correct MDI inhalation technique. The major advantages of nebulizers are that they are effective even in individuals with very low inspiratory flow rates and when coordination with the respiratory cycle is not required.

The nebulizer is a chamber (small cup with a lid) where the liquid medication is aerosolized prior to inhalation. There are two types of nebulizers currently available: pneumatic (jet) nebulizers and ultrasonic (generator) nebulizers.

Pneumatic nebulizers (also known as jet nebulizers or atomizers) use compressed gas (air or oxygen) to convert liquid medication into an aerosol. When the gas hits the liquid, atomization occurs, and small droplets are formed. The distribution of the particles generated by the nebulizer and the deposition in the lungs depend on the design of the nebulizer, the type of baffle (a small plastic piece that causes the liquid medication to convert into droplets), the length of the nebulization, the volume of the drug solution, and the existing temperature, humidity, and surface tension of the liquid.

Ultrasonic nebulizers use electricity to convert liquid medication into respirable droplets. With the use of a piezoelectric crystal, high-frequency electric oscillations are transformed into mechanical oscillations, which provide the energy to produce an aerosol.

Ultrasonic nebulizers tend to deliver a higher rate of drug output in a shorter nebulization time than pneumatic nebulizers. However, the droplets produced by ultrasonic nebulizers can be larger than those formed by pneumatic nebulizers, which may cause the medication to not nebulize properly or uniformly. Although modifications have been made to ultrasonic nebulizers that allow them to produce smaller droplets, the use of pneumatic nebulizers continues to be the standard of care.
References


American Association of Respiratory Care (AARC). AARC Clinical Practice Guideline. Aerosol Delivery Device Selection for Spontaneously Breathing Patients: 2012; 57(4):613-626. Also available on the AARC Web site at:
https://www.aarc.org/wp-content/uploads/2014/08/aerosol_delivery_2012.pdf. Accessed December 20, 2017.

Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2013.

Cates CJ, Crilly JA, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2006.

Global Initiative for Asthma.Global strategy for asthma management and prevention. February 2017. Available at: http://ginasthma.org/2017-gina-report-global-strategy-for-asthma-management-and-prevention/. Accessed 12/21/2018.

Noridian Heathcare Solutions, LLC., Local Coverage Determination (LCD). L33370: Nebulizers. Original: 10/01/15. (Revised: 10/01/17). Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Nebulizers. Accessed November 20, 2017.

Smith LJ. Aerosols. In: Baum GL, Crapo JD, Celli BR, Karlinsky JB, eds. Textbook of Pulmonary Diseases: Volume 1. 6th ed. Philadelphia, PA: Lippincott-Raven;1998:316.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



MEDICALLY NECESSARY

THE FOLLOWING CODES ARE USED TO REPRESENT NEBULIZATION DEVICES AND ACCESSORIES:

A4619 Face tent

A7003 Administration set, with small volume nonfiltered pneumatic nebulizer, disposable

A7004 Small volume nonfiltered pneumatic nebulizer, disposable

A7005 Administration set, with small volume nonfiltered pneumatic nebulizer, non-disposable

A7006 Administration set, with small volume filtered pneumatic nebulizer

A7007 Large volume nebulizer, disposable, unfilled, used with aerosol compressor

A7010 Corrugated tubing, disposable, used with large volume nebulizer, 100 feet

A7012 Water collection device, used with large volume nebulizer

A7013 Filter, disposable, used with aerosol compressor or ultrasonic generator

A7014 Filter, non-disposable, used with aerosol compressor or ultrasonic generator

A7015 Aerosol mask, used with DME nebulizer

A7016 Dome and mouthpiece, used with small volume ultrasonic nebulizer

A7017 Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with oxygen

A7525 Tracheostomy mask, each

E0565 Compressor, air power source for equipment which is not self-contained or cylinder driven

E0570 Nebulizer, with compressor

E0572 Aerosol compressor, adjustable pressure, light duty for intermittent use

E0574 Ultrasonic/electronic aerosol generator with small volume nebulizer

E0580 Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter

E0585 Nebulizer, with compressor and heater

E1372 Immersion external heater for nebulizer

J7699 NOC drugs, inhalation solution administered through DME

K0730 Controlled dose inhalation drug delivery system

S8100 Holding chamber or spacer for use with an inhaler or nebulizer; without mask

S8101 Holding chamber or spacer for use with an inhaler or nebulizer; with mask


THE FOLLOWING CODES ARE USED TO REPRESENT INHALATION DRUGS AND SOLUTIONS:

A4216 Sterile water, saline and/or dextrose, diluent/flush, 10 ml

A4217 Sterile water/saline, 500 ml

A4218 Sterile saline or water, metered dose dispenser, 10 ml

J2545 Pentamidine isethionate, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per 300 mg

J7605 Arformoterol, inhalation solution, FDA approved final product, noncompounded, administered through DME, unit dose form, 15 mcg

J7606 Formoterol fumarate, inhalation solution, FDA approved final product, noncompounded, administered through DME, unit dose form, 20 mcg

J7608 Acetylcysteine, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per g

J7611 Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 1 mg

J7612 Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 0.5 mg

J7613 Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 1 mg

J7614 Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 0.5 mg

J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, noncompounded, administered through DME

J7626 Budesonide, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, up to 0.5 mg

J7631 Cromolyn sodium, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per 10 mg

J7639 Dornase alfa, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per mg

J7644 Ipratropium bromide, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per mg

J7669 Metaproterenol sulfate, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per 10 mg

J7682 Tobramycin, inhalation solution, FDA-approved final product, noncompounded, unit dose form, administered through DME, per 300 mg

J7686 Treprostinil, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, 1.74 mg

J7699 NOC drugs, inhalation solution administered through DME

Q4074 Iloprost, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, up to 20 mcg


NOT MEDICALLY NECESSARY

THE FOLLOWING CODES ARE USED TO REPRESENT COMPOUNDED INHALATION SOLUTIONS:

J7604 Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per g

J7607 Levalbuterol, inhalation solution, compounded product, administered through DME, concentrated form, 0.5 mg

J7609 Albuterol, inhalation solution, compounded product, administered through DME, unit dose, 1 mg

J7610 Albuterol, inhalation solution, compounded product, administered through DME, concentrated form, 1 mg

J7615 Levalbuterol, inhalation solution, compounded product, administered through DME, unit dose, 0.5 mg

J7622 Beclomethasone, inhalation solution, compounded product, administered through DME, unit dose form, per mg

J7624 Betamethasone, inhalation solution, compounded product, administered through DME, unit dose form, per mg

J7627 Budesonide, inhalation solution, compounded product, administered through DME, unit dose form, up to 0.5 mg

J7628 Bitolterol mesylate, inhalation solution, compounded product, administered through DME, concentrated form, per mg

J7629 Bitolterol mesylate, inhalation solution, compounded product, administered through DME, unit dose form, per mg

J7632 Cromolyn sodium, inhalation solution, compounded product, administered through DME, unit dose form, per 10 mg

J7634 Budesonide, inhalation solution, compounded product, administered through DME, concentrated form, per 0.25 mg

J7635 Atropine, inhalation solution, compounded product, administered through DME, concentrated form, per mg

J7636 Atropine, inhalation solution, compounded product, administered through DME, unit dose form, per mg

J7637 Dexamethasone, inhalation solution, compounded product, administered through DME, concentrated form, per mg

J7638 Dexamethasone, inhalation solution, compounded product, administered through DME, unit dose form, per mg

J7640 Formoterol, inhalation solution, compounded product, administered through DME, unit dose form, 12 mcg

J7641 Flunisolide, inhalation solution, compounded product, administered through DME, unit dose, per mg

J7642 Glycopyrrolate, inhalation solution, compounded product, administered through DME, concentrated form, per mg

J7643 Glycopyrrolate, inhalation solution, compounded product, administered through DME, unit dose form, per mg

J7645 Ipratropium bromide, inhalation solution, compounded product, administered through DME, unit dose form, per mg

J7647 Isoetharine HCl, inhalation solution, compounded product, administered through DME, concentrated form, per mg

J7650 Isoetharine HCl, inhalation solution, compounded product, administered through DME, unit dose form, per mg

J7657 Isoproterenol HCl, inhalation solution, compounded product, administered through DME, concentrated form, per mg

J7660 Isoproterenol HCl, inhalation solution, compounded product, administered through DME, unit dose form, per mg

J7667 Metaproterenol sulfate, inhalation solution, compounded product, concentrated form, per 10 mg

J7670 Metaproterenol sulfate, inhalation solution, compounded product, administered through DME, unit dose form, per 10 mg

J7676 Pentamidine isethionate, inhalation solution, compounded product, administered through DME, unit dose form, per 300 mg

J7680 Terbutaline sulfate, inhalation solution, compounded product, administered through DME, concentrated form, per mg

J7681 Terbutaline sulfate, inhalation solution, compounded product, administered through DME, unit dose form, per mg

J7683 Triamcinolone, inhalation solution, compounded product, administered through DME, concentrated form, per mg

J7684 Triamcinolone, inhalation solution, compounded product, administered through DME, unit dose form, per mg

J7685 Tobramycin, inhalation solution, compounded product, administered through DME, unit dose form, per 300 mg


THE FOLLOWING CODE IS USED TO REPRESENT A COMPOUNDED INHALATION SOLUTION

J7699 NOC drugs, inhalation solution administered through DME




Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

05.00.15p:
08/15/2018This policy has been reissued in accordance with the Company's annual review process.
01/26/2018This version of the policy will become effective 01/26/2018. The intent of this policy has not changed, although it has been modified to incorporate compounded inhalation solutions as not medically necessary.

The following HCPCS codes for compounded inhalation solutions have been added to this policy as not medically necessary:

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, J7699.

The following HCPCS codes for inhalation drugs and solutions have been added to this policy as medically necessary:
A4216, A4217, A4218, J2545, J7605, J7606, J7608, J7611, J7612, J7613, J7614, J7620, J7626, J7631, J7639, J7644, J7669, J7682, J7686, J7699, Q4074

The following policy criteria has been revised for a small-volume, nonfiltered nebulizer with compressor and is considered medically necessary when used for the administration of:

  • Albuterol for individuals with asthma/obstructive pulmonary disease when a metered dose inhaler (MDI) with a spacer device was considered inappropriate or was insufficient for the administration of the medication
Version Effective Date: 01/26/2018
Version Issued Date: 01/26/2018
Version Reissued Date: 08/16/2018

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