• Nebulizers Info.

    Coverage Criteria Specific Nebulizers

    • Small volume nebulizer and related compressor – It is documented in the pa-
      tient’s medical record that:

      • It is reasonable and necessary to administer albuterol, arformoterol budesonide, cromolyn, formoterol, ipratropium, levalbuterol, or metaproterenol for the management of obstructive pulmonary disease;
      • It is reasonable and necessary to administer dornase alpha to a pa-tient with cystic fibrosis; or
      • It is reasonable and necessary to administer tobramycin to a patient with cystic fibrosis or bronchiectasis; or
      • It is reasonable and necessary to administer pentamidine to a patient with HIV, pneumocytosis, or complications of organ transplants; or
      • It is reasonable and necessary to administer acetylcysteine for persis-
        tent thick or tenacious pulmonary secretions.
    • Large volume nebulizer, related compressor and water or saline – It is docu-mented in the patient’s medical record that it is reasonable and necessary to deliver humidity to the patient with thick, tenacious secretions, who has cystic fibrosis, brochiectasis, a tracheostomy, or a tracheobronchial stent.
    • Compressor and filtered nebulizer – It is documented in the patient’s medical
      record that it is reasonable and necessary to administer pentamidine to a pa-
      tient with HIV, pneumocytosis, or complications of organ transplants.
    • Small volume nebulizer and related accessories – It is documented in the pa-
      tient’s medical record that it is reasonable and necessary to administer treprostinil solution only.