Nebulizers

Note:  The following coverage criteria is for Medicare, other insurances may have different criteria and may be less stringent.  In most cases, meeting Medicare criteria will meet all other criteria’s.

• A written signed and dated prescription prior to dispensing is required before a nebulizer is covered by Medicare.
• The face to face notes must include the conditions for coverage  as described below (these must be completed and signed prior to dispensing the item):

A small volume nebulizer (A7043, A7404, A7005) and related compressor (E0570, E0571) are covered when:

1. 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.

For criterion (a) to be met, the physician must have considered use of a metered dose inhaler (MDI) with and without a reservoir or spacer device and decided that, for medical reasons, it was not sufficient for the administration of needed inhalation drugs. The reason for requiring a small volume nebulizer and related compressor/ generator instead of or in addition to an MDI must be documented in the patient's medical record and be available to the DMERC on request.