Respiratory Rules and Limits
Rules and Limits Having trouble finding the Respiratory Supplies you need or finding a supplier that will accept Medicare Assignment? Better Living Now is here to help you. We carry all your supplies and we work with you towards providing your supplies under Medicare assignment through our Preferred Program. If you are covered under Medicare, many of your medically necessary supplies and related products may be covered! To get started enroll today or print out an Respiratory Supplies Order Form, bring it to your doctor and mail your or fax your order to us. It is that easy! How The Program Works
Respiratory Supplies Allowable Amounts
Allowable Amounts Better Living Now has developed preferred product relationships with industry leading manufacturers in an effort to bring you the highest quality products available that will be 100% covered by your insurance/Medicare plan with no additional out-of-pocket expense to you. Contact us for more information Respiratory Supplies Allowable Amounts - Effective 08/02/2011
Product Description Allowable Amount
E0565
COMPRESSOR, AIR POWER SOURCE FOR EQUIPMENT WHICH IS NOT SELFCONTAINED 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
E0575
NEBULIZER, ULTRASONIC, LARGE VOLUME
E0585
NEBULIZER, WITH COMPRESSOR AND HEATER
K0730
CONTROLLED DOSE INHALATION DRUG DELIVERY SYSTEM
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
A7008
LARGE VOLUME NEBULIZER, DISPOSABLE, PREFILLED, USED WITH AEROSOL COMPRESSOR
A7009
RESERVOIR BOTTLE, NON-DISPOSABLE, USED WITH LARGE VOLUME ULTRASONIC NEBULIZER
A7010
CORRUGATED TUBING, DISPOSABLE, USED WITH LARGE VOLUME NEBULIZER, 100 FEET
A7011
CORRUGATED TUBING, NON-DISPOSABLE, USED WITH LARGE VOLUME NEBULIZER,10 FEET
A7012
WATER COLLECTION DEVICE, USED WITH LARGE VOLUME NEBULIZER
A7013
FILTER, DISPOSABLE, USED WITH AEROSOL COMPRESSOR OR ULTRASONIC GENERATOR
A7014
FILTER, NONDISPOSABLE, 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
E0580
NEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER
E1372
IMMERSION EXTERNAL HEATER FOR NEBULIZER
Notes - none INHALATION DRUGS
Product Description Allowable Amount
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
G0333
PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS A BENEFICIARY
J2545
PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MG
J7604
ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM
J7605
ARFORMOTEROL, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 15 MICROGRAMS
J7606
FORMOTEROL FUMARATE, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 20 MICROGRAMS
J7607
LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 0.5 MG
J7608
ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM
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
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
J7615
LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG
J7620
ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDAAPPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME
J7622
BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
J7624
BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
J7626
BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 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 MILLIGRAM
J7629
BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
J7631
CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON -COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS
J7632
CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS
J7634
BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM
J7635
ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM
J7636
ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
J7637
DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM
J7638
DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
J7639
DORNASE ALFA, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
J7640
FORMOTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 12 MICROGRAMS
J7641
FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE, PER MILLIGRAM
J7642
GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM
J7643
GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
J7644
IPRATROPIUM BROMIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
J7645
IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
J7647
ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM
J7650
ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
J7657
ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM
J7660
ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
J7667
METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, CONCENTRATED FORM, PER 10 MILLIGRAMS
J7669
METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS
J7670
METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS
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 MILLIGRAM
J7681
TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
J7682
TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONCOMPOUNDED, UNIT DOSE FORM, ADMINISTERED THROUGH DME, PER 300 MILLIGRAMS
J7683
TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM
J7684
TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
J7685
TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MILLIGRAMS
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
Q0513
PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); PER 30 DAYS
Q0514
PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); PER 90 DAYS
Q4074
ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 20 MICROGRAMS
Notes - none ICD-9 Codes that Support Medical Necessity
The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on "Indications and Limitations of Coverage and/or Medical Necessity" for other coverage criteria and payment information. For HCPCS codes A4619, E0565, E0572:
Product Description Allowable Amount
011.50 - 011.56
TUBERCULOUS BRONCHIECTASIS UNSPECIFIED EXAMINATION - TUBERCULOUS BRONCHIECTASIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
042
HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
136.3
PNEUMOCYSTOSIS
277.02
CYSTIC FIBROSIS WITH PULMONARY MANIFESTATIONS
494.0
BRONCHIECTASIS WITHOUT ACUTE EXACERBATION
494.1
BRONCHIECTASIS WITH ACUTE EXACERBATION
519.19
OTHER DISEASES OF TRACHEA AND BRONCHUS
748.61
CONGENITAL BRONCHIECTASIS
996.80 - 996.89
COMPLICATIONS OF UNSPECIFIED TRANSPLANTED ORGAN - COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN
V44.0
TRACHEOSTOMY STATUS
V55.0
ATTENTION TO TRACHEOSTOMY
Notes - none For HCPCS codes A7015, A7525:
Product Description Allowable Amount
011.50 - 011.56
TUBERCULOUS BRONCHIECTASIS UNSPECIFIED EXAMINATION - TUBERCULOUS BRONCHIECTASIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
042
HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
136.3
PNEUMOCYSTOSIS
277.02
CYSTIC FIBROSIS WITH PULMONARY MANIFESTATIONS
480.0 - 508.9
PNEUMONIA DUE TO ADENOVIRUS - RESPIRATORY CONDITIONS DUE TO UNSPECIFIED EXTERNAL AGENT
519.19
OTHER DISEASES OF TRACHEA AND BRONCHUS
748.61
CONGENITAL BRONCHIECTASIS
786.4
ABNORMAL SPUTUM
996.80 - 996.89
COMPLICATIONS OF UNSPECIFIED TRANSPLANTED ORGAN - COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN
V44.0
TRACHEOSTOMY STATUS
V55.0
ATTENTION TO TRACHEOSTOMY
Notes - none For HCPCS codes A7003, A7004, E0570:
Product Description Allowable Amount
011.50 - 011.56
TUBERCULOUS BRONCHIECTASIS UNSPECIFIED EXAMINATION - TUBERCULOUS BRONCHIECTASIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
042
HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
136.3
PNEUMOCYSTOSIS
277.02
CYSTIC FIBROSIS WITH PULMONARY MANIFESTATIONS
480.0 - 508.9
PNEUMONIA DUE TO ADENOVIRUS - RESPIRATORY CONDITIONS DUE TO UNSPECIFIED EXTERNAL AGENT
748.61
CONGENITAL BRONCHIECTASIS
786.4
ABNORMAL SPUTUM
996.80 - 996.89
COMPLICATIONS OF UNSPECIFIED TRANSPLANTED ORGAN - COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN
Notes - none For HCPCS codes A7006, J2545:
Product Description Allowable Amount
042
HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
136.3
PNEUMOCYSTOSIS
996.80 - 996.89
COMPLICATIONS OF UNSPECIFIED TRANSPLANTED ORGAN - COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN
Notes - none For HCPCS codes A4217, A7007, A7010, A7011, A7012, A7017, A7018, E0585, E1372:
Product Description Allowable Amount
011.50 - 011.56
TUBERCULOUS BRONCHIECTASIS UNSPECIFIED EXAMINATION - TUBERCULOUS BRONCHIECTASIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
277.02
CYSTIC FIBROSIS WITH PULMONARY MANIFESTATIONS
494.0
BRONCHIECTASIS WITHOUT ACUTE EXACERBATION
494.1
BRONCHIECTASIS WITH ACUTE EXACERBATION
519.19
OTHER DISEASES OF TRACHEA AND BRONCHUS
748.61
CONGENITAL BRONCHIECTASIS
V44.0
TRACHEOSTOMY STATUS
V55.0
ATTENTION TO TRACHEOSTOMY
Notes - none For HCPCS code A4216:
Product Description Allowable Amount
042
HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
136.3
PNEUMOCYSTOSIS
491.0 - 508.9
SIMPLE CHRONIC BRONCHITIS - RESPIRATORY CONDITIONS DUE TO UNSPECIFIED EXTERNAL AGENT
996.80 - 996.89
COMPLICATIONS OF UNSPECIFIED TRANSPLANTED ORGAN - COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN
Notes - none For HCPCS codes J7608:
Product Description Allowable Amount
480.0 - 508.9
PNEUMONIA DUE TO ADENOVIRUS - RESPIRATORY CONDITIONS DUE TO UNSPECIFIED EXTERNAL AGENT
786.4
ABNORMAL SPUTUM
Notes - none For HCPCS codes J7605, J7606, J7611, J7612, J7613, J7614, J7620, J7626, J7631, J7644, J7669:
Product Description Allowable Amount
491.0 - 508.9
SIMPLE CHRONIC BRONCHITIS - RESPIRATORY CONDITIONS DUE TO UNSPECIFIED EXTERNAL AGENT
Notes - none For HCPCS code J7639:
Product Description Allowable Amount
277.02
CYSTIC FIBROSIS WITH PULMONARY MANIFESTATIONS
Notes - none For HCPCS code J7682:
Product Description Allowable Amount
011.50 - 011.56
TUBERCULOUS BRONCHIECTASIS UNSPECIFIED EXAMINATION - TUBERCULOUS BRONCHIECTASIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
277.02
CYSTIC FIBROSIS WITH PULMONARY MANIFESTATIONS
494.0
BRONCHIECTASIS WITHOUT ACUTE EXACERBATION
494.1
BRONCHIECTASIS WITH ACUTE EXACERBATION
748.61
CONGENITAL BRONCHIECTASIS
Notes - none For HCPCS codes A7016, E0574, J7686 K0730, Q4074:
Product Description Allowable Amount
416.0
PRIMARY PULMONARY HYPERTENSION
416.8
OTHER CHRONIC PULMONARY HEART DISEASES
Notes - none For HCPCS code A7005:
Product Description Allowable Amount
011.50 - 011.56
TUBERCULOUS BRONCHIECTASIS UNSPECIFIED EXAMINATION - TUBERCULOUS BRONCHIECTASIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
042
HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
136.3
PNEUMOCYSTOSIS
277.02
CYSTIC FIBROSIS WITH PULMONARY MANIFESTATIONS
416.0
PRIMARY PULMONARY HYPERTENSION
416.8
OTHER CHRONIC PULMONARY HEART DISEASES
480.0 - 508.9
PNEUMONIA DUE TO ADENOVIRUS - RESPIRATORY CONDITIONS DUE TO UNSPECIFIED EXTERNAL AGENT
748.61
CONGENITAL BRONCHIECTASIS
786.4
ABNORMAL SPUTUM
996.80 - 996.89
COMPLICATIONS OF UNSPECIFIED TRANSPLANTED ORGAN - COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN
Notes - none For HCPCS codes A7013, A7014:
Product Description Allowable Amount
011.50 - 011.56
TUBERCULOUS BRONCHIECTASIS UNSPECIFIED EXAMINATION - TUBERCULOUS BRONCHIECTASIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
042
HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
136.3
PNEUMOCYSTOSIS
277.02
CYSTIC FIBROSIS WITH PULMONARY MANIFESTATIONS
416.0
PRIMARY PULMONARY HYPERTENSION
416.8
OTHER CHRONIC PULMONARY HEART DISEASES
480.0 - 508.9
PNEUMONIA DUE TO ADENOVIRUS - RESPIRATORY CONDITIONS DUE TO UNSPECIFIED EXTERNAL AGENT
519.19
OTHER DISEASES OF TRACHEA AND BRONCHUS
748.61
CONGENITAL BRONCHIECTASIS
786.4
ABNORMAL SPUTUM
996.80 - 996.89
COMPLICATIONS OF UNSPECIFIED TRANSPLANTED ORGAN - COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN
V44.0
TRACHEOSTOMY STATUS
V55.0
ATTENTION TO TRACHEOSTOMY
Notes Diagnoses that Support Medical Necessity
Refer to the previous section for the specific HCPCS code indicated. For all other HCPCS codes listed in the policy refer to the section on "Indications and Limitations of Coverage and/or Medical Necessity" for other criteria and payment information. ICD-9 Codes that DO NOT Support Medical Necessity
For the specific HCPCS codes indicated above, all ICD-9 codes that are not specified in the previous section. For HCPCS codes A7009, E0575, 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, and J7685, all ICD-9 codes. For all other HCPCS codes, ICD-9 codes are not specified. ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation Diagnoses that DO NOT Support Medical Necessity
For the specific HCPCS codes indicated above, all diagnoses that are not specified in the previous section. For HCPCS codes A7009, E0575, 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, and J7685, all diagnoses. For all other HCPCS codes, diagnoses are not specified.
Respiratory Supplies Guidelines
General Information For more information on local coverage determination
Local Coverage Determination (LCD) for Respiratory Supplies
Indications and Limitations of Coverage 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 indications and limitations of coverage and/or medical necessity. For an item to be covered by Medicare, a written signed and dated order 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 order, the item will be denied as not reasonable and necessary. A small volume nebulizer (A7003, A7004, A7005), related compressor (E0570), and FDA-approved inhalation solutions of the drugs listed below are covered when: a. 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 (ICD-9 diagnosis codes 491.0-508.9); or b. It is reasonable and necessary to administer dornase alpha (J7639) to a patient with cystic fibrosis (ICD-9 diagnosis code 277.02); or c. It is reasonable and necessary to administer tobramycin (J7682) to a patient with cystic fibrosis or bronchiectasis (ICD-9 diagnosis code 277.02, 494.0, 494.1, 748.61, 011.50-011.56); or d. It is reasonable and necessary to administer pentamidine (J2545) to a patient with HIV (ICD-9 diagnosis code 042), pneumocystosis (ICD-9 diagnosis code 136.3), or complications of organ transplants (ICD-9 diagnosis codes 996.80-996.89); or e. It is reasonable and necessary to administer acetylcysteine (J7608) for persistent thick or tenacious pulmonary secretions (ICD-9 diagnosis codes 480.0-508.9, 786.4). 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 patient with thick, tenacious secretions, who has cystic fibrosis (ICD-9 diagnosis code 277.02), bronchiectasis (ICD-9 diagnosis code 494.0, 494.1, 011.50-011.56 or 748.61), a tracheostomy (ICD-9 diagnosis code V44.0 or V55.0), or a tracheobronchial stent (ICD-9 diagnosis code 519.19). 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 patients with HIV (ICD-9 diagnosis code 042), pneumocystosis (ICD-9 diagnosis code 136.3) or complications of organ transplants (ICD-9 diagnosis codes 996.80-996.89). 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: 1. The patient has a diagnosis of pulmonary artery hypertension (ICD-9 diagnosis codes 416.0 or 416.8); and 2. 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 3. The patient 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: a. The pulmonary hypertension has progressed despite maximal medical and/or surgical treatment of the identified condition; and b. The mean pulmonary artery pressure is > 25 mm Hg at rest or > 30 mm Hg with exertion; and c. The patient has significant symptoms from the pulmonary hypertension (i.e., severe dyspnea on exertion, and either fatigability, angina, or syncope); and d. 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 patients with pulmonary hypertension (ICD-9 diagnosis codes 416.0 or 416.8) only. 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 medically unnecessary.
Compressor / Generator Related Accessories
E0565 A4619, A7006, A7007, A7010, A7011, A7012, A7013, A7014, A7015, A7017, A7525, E1372
E0570 A7003, A7004, A7005, A7006, A7013, A7015, A7525
E0572 A7006, A7014
E0574 A7013, A7014, A7016
E0585 A4619, A7006, A7010, A7011, A7012, A7013, A7014, A7015, A7525
K0730 A7005
Notes 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.
Accessory Usual maximum replacement
A4619 One/month
A7003 Two/month
A7004 Two/month (in addition to A7003)
A7005 One/6 months
A7005 One/3 months only with K0730
A7006 One/month
A7007 Two/month
A7010 One unit (100 ft.)/2 months
A7011 One/year
A7012 Two/month
A7013 Two/month
A7014 One/3 months
A7015 One/month
A7016 Two/year
A7017 One/3 years
A7525 One/month
E1372 One/3 years
Notes - none 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 Solutions Maximum Milligrams/Month
Acetylcysteine 74 grams/month
Albuterol 465 mg/month (See below for exception)
Albuterol/Ipratropium combination 186 units/month
Arformoterol 930 micrograms/month - 62 units/month
Budesonide 62 units/month
Cromolyn sodium 2480 mg/month - 248 units/month
Dornase alpha 78 mg/month
Formoterol 1240 micrograms/month - 62 units/month
Ipratropium bromide 93 mg/month
Levalbuterol 232.5 mg/month - 465 units/month (See below for exception)
Metaproterenol 2800 mg/month - 280 units/month (See below for exception)
Pentamidine 300 mg/month
Treprostinil 31 units/month
Sterile saline or water, 10ml/unit (A4216, A4218) 56 units/month
Distilled water, sterile water, or sterile saline in large volume nebulizer 18 liters/month
Notes - none When albuterol, levalbuterol, or metaproterenol are prescribed as rescue/supplemental medication for patients who are taking formoterol or arformoterol, the maximum milligrams/month that are reasonably billed are:
Inhalation Drugs and Solutions Maximum Milligrams/Month
Albuterol 78 mg/month
Albuterol/Ipratropium combination 31 units/month
Levalbuterol 39 mg/month (78 units/month)
Metaproterenol 470 mg/month (47 units/month)
Notes 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 patients 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 patient 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 patient 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. Documentations Requirements
Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request. An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code. The order for any drug must clearly specify the type of solution to be dispensed to the patient and the administration instructions for that solution. The type of solution is described by a combination of (a) the name of the drug and the concentration of the drug in the dispensed solution and the volume of solution in each container, or (b) the name of the drug and the number of milligrams/grams of drug in the dispensed solution and the volume of solution in that container. Examples of (a) would be: albuterol 0.083% 3 ml; or albuterol 0.5% 20 ml; or cromolyn 20 mg/2 ml. An example of (b) is: albuterol 1.25 mg in 3 ml saline. For compounded inhalation solutions, the order must include the following statement prior to signature by the physician: compounded inhalation solution - not FDA-approved. Administration instructions must specify the amount of solution and specific frequency of use. As noted in the Program Integrity Manual (Internet-Only Manual, Pub. 100-8), Chapter 5, Section 5.9 "...do not accept 'PRN' or 'as needed' utilization estimates for supply replacement, use, or consumption." For orders that include "PRN" or "as needed", reimbursement will be based on the specified frequency of use on the order only. REFILLS: A routine refill prescription is not needed. A new prescription is needed when: • There is a change of supplier • There is a change in treating physician • There is a change in the item(s), frequency of use, or amount prescribed • There is a change in the length of need or a previously established length of need expires • State law requires periodic prescription renewal For items that the patient obtains in person at a retail store, the signed delivery slip or copy of itemized sales receipt is sufficient documentation of a request for refill. For items that are delivered to the beneficiary, documentation of a request for refill must be either a written document received from the beneficiary or a contemporaneous written record of a phone conversation/contact between the supplier and beneficiary. The refill request must occur and be documented before shipment. A retrospective attestation statement by the supplier or beneficiary is not sufficient. The refill record must include: • Beneficiary's name or authorized representative if different than the beneficiary • A description of each item that is being requested • Date of refill request • Quantity of each item that the beneficiary still has remaining This information must be kept on file and be available upon request. An ICD-9 code describing the condition which necessitates nebulizer therapy must be included on each claim for equipment, accessories, and/or drugs. KX, GA, AND GZ MODIFIERS: Suppliers must add a KX modifier to codes for E0574,J7686, K0730 and Q4074 only if all of the criteria in the Indications and Limitations of Coverage and/or Medical Necessity section of this policy have been met. If all of the criteria in the Indications and Limitations of Coverage and/or Medical Necessity section have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter GA on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or GZ if they have not obtained a valid ABN. Claim lines billed without a KX, GA, or GZ modifier will be rejected as missing information. MISCELLANEOUS When code E1399 is billed for miscellaneous equipment or accessories, the claim must be accompanied by a clear description of the item including the manufacturer and the model name/number if applicable. When Not Otherwise Classified (NOC) drug code J7699 is billed for miscellaneous inhalation drugs, the claim must be accompanied by the detailed order information described above and a clear statement of the number of ampules/bottles of solution dispensed. Refer to the Supplier Manual for more information on documentation requirements.
Refills
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 predetermined 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. 100-8, 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.
For more information on local coverage determination
Local Coverage Determination (LCD) for Respiratory Supplies

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