A small volume nebulizer (A7003, A7004, A7005), and related compressor are considered for coverage when it is reasonable and necessary to administer the following FDA-approved inhalation solutions listed below (refer to the Group 3 Codes in the LCD-related Policy Article for applicable diagnoses):
- It is reasonable and necessary to administer albuterol, arformoterol, budesonide, cromolyn, formoterol, ipratropium, levalbuterol, metaproterenol, or revefenacin for the management of obstructive pulmonary disease or
- It is reasonable and necessary to administer dornase alfa to a beneficiary with cystic fibrosis; or
- It is reasonable and necessary to administer tobramycin to a beneficiary with cystic fibrosis or bronchiectasis; or
- It is reasonable and necessary to administer pentamidine to a beneficiary with HIV, pneumocystosis, or complications of organ transplants; or
- It is reasonable and necessary to administer acetylcysteine for persistent thick or tenacious pulmonary secretions.