Aetna · Clinical coverage policy

Aetna Nebulizers coverage criteria

Aetna CPB 0065 covers nebulizers (small volume, large volume, and ultrasonic) and related compressors/accessories only when used to administer specifically named drugs for specifically named conditions -- e.g., antibiotics, dornase alfa, or aztreonam for cystic fibrosis; bronchodilators/corticosteroids for COPD (with the gate that an MDI with/without spacer was tried and found insufficient); pentamidine for HIV; and treprostinil/iloprost for pulmonary hypertension. Any nebulizer use outside the listed drug-and-indication pairs, plus a specific list of nebulized therapies (e.g., nebulized magnesium for pediatric asthma, nebulized lidocaine, nebulized heparin, nebulized corticosteroids for nasal polyps or viral wheezing), is considered experimental/investigational and not covered. The bulletin is silent on whether precertification is required.

Policy CPB 0065 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0065

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0065 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Nebulizers (CPT E0565), and what gets it denied?

Path
Aetna CPB 0065 covers nebulizers (small volume, large volume, and ultrasonic) and related compressors/accessories only when used to administer specifically named drugs for specifically named conditions -- e.g., antibiotics, dornase alfa, or aztreonam for cystic fibrosis; bronchodilators/corticosteroids for COPD (with the gate that an MDI with/without spacer was tried and found insufficient); pentamidine for HIV; and treprostinil/iloprost for pulmonary hypertension. Any nebulizer use outside the listed drug-and-indication pairs, plus a specific list of nebulized therapies (e.g., nebulized magnesium for pediatric asthma, nebulized lidocaine, nebulized heparin, nebulized corticosteroids for nasal polyps or viral wheezing), is considered experimental/investigational and not covered. The bulletin is silent on whether precertification is required. Coverage criteria include: Small volume nebulizer is medically necessary to administer antibiotics (gentamicin, amikacin, or tobramycin) to members with cystic fibrosis (CF) or bronchiectasis; Small volume nebulizer is medically necessary to administer beta-adrenergics (albuterol, isoproterenol, isoetharine, levalbuterol, metaproterenol), anticholinergics (ipratropium), corticosteroids (budesonide), and cromolyn for the management of chronic obstructive pulmonary disease (COPD) -- CONDITION: 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; Small volume nebulizer is medically necessary to administer dornase alfa (Pulmozyme) to members with CF or primary ciliary dyskinesia; Small volume nebulizer is medically necessary to administer epinephrine for the treatment of croup; Small volume nebulizer is medically necessary to administer formoterol (Perforomist) or arformoterol (Brovana) for the management of COPD when medical necessity criteria in the Pharmacy Clinical Policy Bulletin on 'Long-Acting Beta Agonists' are met; Small volume nebulizer is medically necessary to administer treprostinil inhalation solution (Tyvaso) via an ultrasonic pulsed delivery device (the Tyvaso Inhalation System) or iloprost (Ventavis) via a controlled dose inhalation drug delivery system (i.e., the I-neb or the Prodose nebulizer) to members with pulmonary hypertension; Small volume nebulizer is medically necessary to administer mucolytics other than dornase alfa (acetylcysteine) for persistent thick or tenacious pulmonary secretions; Small volume nebulizer is medically necessary to administer pentamidine to members with HIV, pneumocystosis, or complications of organ transplants; Small volume nebulizer is medically necessary to administer colistin for multi-drug resistant P. aeruginosa pneumonia failing to improve on IV therapy; Small volume nebulizer is medically necessary to administer aztreonam inhalation solution (Cayston) to persons with CF with Pseudomonas aeruginosa; The Altera Nebulizer System is medically necessary ONLY to administer aztreonam inhalation solution (Cayston), consistent with FDA-approved labeling requiring this specific device; More than 1 nebulizer may be medically necessary for members who are prescribed nebulized dornase alfa (Pulmozyme) PLUS other nebulized medications, because FDA-approved labeling instructs that dornase alfa should not be diluted or mixed with other drugs in the nebulizer; The Pari-LC Plus Vented Jet Nebulizer is medically necessary for pulmonary administration of aerosolized tobramycin, based on comparative studies showing adequate lung delivery; Large volume nebulizer, related compressor, and water or saline DME to deliver humidity is medically necessary for a person with thick, tenacious secretions when ANY ONE of the following is present: (a) administration of pentamidine for members with HIV, pneumocystosis, and complications of organ transplants; (b) bronchiectasis; (c) cystic fibrosis; (d) tracheobronchial stent; (e) tracheostomy; Ultrasonic nebulizer DME for delivery of tobramycin (TOBI) for members with CF is medically necessary when ALL of the following are met: (1) the member meets the criteria for a standard nebulizer; (2) the primary care physician and specialist indicate that the member has been compliant with other nebulizer and medication therapy; (3) the use of a standard nebulizer has failed to control the member's disease and prevent the member from utilizing the hospital or emergency room; Replacement of nebulizers (for members with DME benefits) is medically necessary on an individual basis when BOTH of the following are met: (1) the primary care physician and/or specialist confirm that the member has been compliant with the nebulizer and anticipate the need for continued use to prevent a hospital admission or emergency room visits; AND (2) the warranty has expired; A battery-powered compressor is rarely medically necessary; accompanying documentation must be submitted justifying its medical necessity; A spring-loaded valve is medically necessary for persons on a ventilator who meet the criteria for a nebulizer; Maximum frequency of accessory replacement considered medically necessary (per item): administration set small volume filtered pneumatic 1/month; administration set small volume non-filtered disposable 2/month; administration set small volume non-filtered non-disposable 1 per 6 months; aerosol mask 1/month; corrugated tubing disposable (large volume) 100 feet per 2 months; corrugated tubing non-disposable (large volume) 10 feet/year; dome and mouthpiece (small volume ultrasonic) 2/year; face tent 1/month; filter disposable (compressor) 2/month; filter non-disposable (compressor/ultrasonic) 1 per 3 months; immersion external heater 1 per 3 years; durable glass or autoclavable plastic bottle-type nebulizer not used with oxygen 1 per 3 years; small volume non-filtered pneumatic nebulizer disposable 2/month; tracheostomy mask or collar 1/month; water collection device (large volume) 2/month. Applies to 22 codes: E0565, E0570, E0572, E0574, E0580, E0585, A7003, A7004, A7005, A7006, A7009, A7010, A7012, A7013, A7014, A7015, A7016, A7017, A7018, 94640, 94642, 94664.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: The plan of care must contain the specific condition of the patient justifying the medical necessity of each item; The order for any drug must clearly specify the type of solution to be dispensed and the administration instructions for that solution; the type of solution is described by a combination of either (1) the name of the drug, the concentration of the drug in the dispensed solution, and the volume of solution in each container, OR (2) the name of the drug, the number of milligrams/grams of drug in the dispensed solution, and the volume of solution in that container; A narrative diagnosis and/or an ICD diagnosis code describing the condition must be present on each order; An ICD code describing the condition that necessitates nebulizer therapy must be included on each claim for equipment, accessories, and/or drugs; The patient's medical record must contain information that supports the medical necessity for all equipment, accessories, drugs, and other supplies that are ordered; For a battery-powered compressor, accompanying documentation must be submitted justifying its medical necessity.
Trap
Policy exclusions and limitations: The Amnio Breathe Nebulizer is considered experimental, investigational, or unproven; Nebulized corticosteroids for the treatment of nasal polyps, including in the pre- and post-polypectomy periods, are experimental, investigational, or unproven, because of insufficient evidence of clinical value over established forms of nasal corticosteroid administration (e.g., nasal spray, metered-dose nasal inhaler); Nebulized corticosteroids for the prevention and treatment of viral wheezing are experimental, investigational, or unproven; Nebulized heparin for inhalation injury in burn victims is experimental, investigational, or unproven; Nebulized lidocaine for pain relief for nasogastric tube insertion in children is experimental, investigational, or unproven; Nebulized lidocaine for the treatment of chronic cough is experimental, investigational, or unproven; Nebulized magnesium for the treatment of pediatric asthma is experimental, investigational, or unproven; Nebulized sodium nitrite for the treatment of pulmonary hypertension in individuals with beta-thalassemia is experimental, investigational, or unproven; Small volume nebulizers and related compressors are experimental, investigational, or unproven for all indications other than those listed as medically necessary, because effectiveness for other indications has not been established; Large volume nebulizers and related compressors are experimental, investigational, or unproven for all indications other than those listed as medically necessary, because effectiveness for other indications has not been established; Ultrasonic nebulizers are experimental, investigational, or unproven for all indications other than those listed as medically necessary, because effectiveness for other indications has not been established; Use of dornase alfa (Pulmozyme) for non-CF indications (e.g., asthma, chronic bronchitis, Niemann-Pick type C, and post-lung transplantation) is experimental, investigational, or unproven; The Pari-LC Jet Plus brand of nebulizer is NOT medically necessary for nebulization of budesonide inhalation suspension (Pulmicort Respules), because other jet nebulizers deliver effective doses; Ultrasonic nebulizers are not recommended for delivering inhaled budesonide, having been found in clinical studies to be inefficient at delivering it; Breath-enhanced nebulizers have no proven value over conventional jet nebulizers for the treatment of asthma; Kits and concentrates for use in cleaning respiratory equipment are not covered (consistent with Medicare's policy). Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0065 — Nebulizers

Coverage criteria

  • Small volume nebulizer is medically necessary to administer antibiotics (gentamicin, amikacin, or tobramycin) to members with cystic fibrosis (CF) or bronchiectasis
  • Small volume nebulizer is medically necessary to administer beta-adrenergics (albuterol, isoproterenol, isoetharine, levalbuterol, metaproterenol), anticholinergics (ipratropium), corticosteroids (budesonide), and cromolyn for the management of chronic obstructive pulmonary disease (COPD) -- CONDITION: 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
  • Small volume nebulizer is medically necessary to administer dornase alfa (Pulmozyme) to members with CF or primary ciliary dyskinesia
  • Small volume nebulizer is medically necessary to administer epinephrine for the treatment of croup
  • Small volume nebulizer is medically necessary to administer formoterol (Perforomist) or arformoterol (Brovana) for the management of COPD when medical necessity criteria in the Pharmacy Clinical Policy Bulletin on 'Long-Acting Beta Agonists' are met
  • Small volume nebulizer is medically necessary to administer treprostinil inhalation solution (Tyvaso) via an ultrasonic pulsed delivery device (the Tyvaso Inhalation System) or iloprost (Ventavis) via a controlled dose inhalation drug delivery system (i.e., the I-neb or the Prodose nebulizer) to members with pulmonary hypertension
  • Small volume nebulizer is medically necessary to administer mucolytics other than dornase alfa (acetylcysteine) for persistent thick or tenacious pulmonary secretions
  • Small volume nebulizer is medically necessary to administer pentamidine to members with HIV, pneumocystosis, or complications of organ transplants
  • Small volume nebulizer is medically necessary to administer colistin for multi-drug resistant P. aeruginosa pneumonia failing to improve on IV therapy
  • Small volume nebulizer is medically necessary to administer aztreonam inhalation solution (Cayston) to persons with CF with Pseudomonas aeruginosa
  • The Altera Nebulizer System is medically necessary ONLY to administer aztreonam inhalation solution (Cayston), consistent with FDA-approved labeling requiring this specific device
  • More than 1 nebulizer may be medically necessary for members who are prescribed nebulized dornase alfa (Pulmozyme) PLUS other nebulized medications, because FDA-approved labeling instructs that dornase alfa should not be diluted or mixed with other drugs in the nebulizer
  • The Pari-LC Plus Vented Jet Nebulizer is medically necessary for pulmonary administration of aerosolized tobramycin, based on comparative studies showing adequate lung delivery
  • Large volume nebulizer, related compressor, and water or saline DME to deliver humidity is medically necessary for a person with thick, tenacious secretions when ANY ONE of the following is present: (a) administration of pentamidine for members with HIV, pneumocystosis, and complications of organ transplants; (b) bronchiectasis; (c) cystic fibrosis; (d) tracheobronchial stent; (e) tracheostomy
  • Ultrasonic nebulizer DME for delivery of tobramycin (TOBI) for members with CF is medically necessary when ALL of the following are met: (1) the member meets the criteria for a standard nebulizer; (2) the primary care physician and specialist indicate that the member has been compliant with other nebulizer and medication therapy; (3) the use of a standard nebulizer has failed to control the member's disease and prevent the member from utilizing the hospital or emergency room
  • Replacement of nebulizers (for members with DME benefits) is medically necessary on an individual basis when BOTH of the following are met: (1) the primary care physician and/or specialist confirm that the member has been compliant with the nebulizer and anticipate the need for continued use to prevent a hospital admission or emergency room visits; AND (2) the warranty has expired
  • A battery-powered compressor is rarely medically necessary; accompanying documentation must be submitted justifying its medical necessity
  • A spring-loaded valve is medically necessary for persons on a ventilator who meet the criteria for a nebulizer
  • Maximum frequency of accessory replacement considered medically necessary (per item): administration set small volume filtered pneumatic 1/month; administration set small volume non-filtered disposable 2/month; administration set small volume non-filtered non-disposable 1 per 6 months; aerosol mask 1/month; corrugated tubing disposable (large volume) 100 feet per 2 months; corrugated tubing non-disposable (large volume) 10 feet/year; dome and mouthpiece (small volume ultrasonic) 2/year; face tent 1/month; filter disposable (compressor) 2/month; filter non-disposable (compressor/ultrasonic) 1 per 3 months; immersion external heater 1 per 3 years; durable glass or autoclavable plastic bottle-type nebulizer not used with oxygen 1 per 3 years; small volume non-filtered pneumatic nebulizer disposable 2/month; tracheostomy mask or collar 1/month; water collection device (large volume) 2/month

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • The plan of care must contain the specific condition of the patient justifying the medical necessity of each item
  • The order for any drug must clearly specify the type of solution to be dispensed and the administration instructions for that solution; the type of solution is described by a combination of either (1) the name of the drug, the concentration of the drug in the dispensed solution, and the volume of solution in each container, OR (2) the name of the drug, the number of milligrams/grams of drug in the dispensed solution, and the volume of solution in that container
  • A narrative diagnosis and/or an ICD diagnosis code describing the condition must be present on each order
  • An ICD code describing the condition that necessitates nebulizer therapy must be included on each claim for equipment, accessories, and/or drugs
  • The patient's medical record must contain information that supports the medical necessity for all equipment, accessories, drugs, and other supplies that are ordered
  • For a battery-powered compressor, accompanying documentation must be submitted justifying its medical necessity

Frequently asked questions

When does Aetna cover Nebulizers (CPT E0565), and what gets it denied?
Aetna CPB 0065 covers nebulizers (small volume, large volume, and ultrasonic) and related compressors/accessories only when used to administer specifically named drugs for specifically named conditions -- e.g., antibiotics, dornase alfa, or aztreonam for cystic fibrosis; bronchodilators/corticosteroids for COPD (with the gate that an MDI with/without spacer was tried and found insufficient); pentamidine for HIV; and treprostinil/iloprost for pulmonary hypertension. Any nebulizer use outside the listed drug-and-indication pairs, plus a specific list of nebulized therapies (e.g., nebulized magnesium for pediatric asthma, nebulized lidocaine, nebulized heparin, nebulized corticosteroids for nasal polyps or viral wheezing), is considered experimental/investigational and not covered. The bulletin is silent on whether precertification is required. Coverage criteria include: Small volume nebulizer is medically necessary to administer antibiotics (gentamicin, amikacin, or tobramycin) to members with cystic fibrosis (CF) or bronchiectasis; Small volume nebulizer is medically necessary to administer beta-adrenergics (albuterol, isoproterenol, isoetharine, levalbuterol, metaproterenol), anticholinergics (ipratropium), corticosteroids (budesonide), and cromolyn for the management of chronic obstructive pulmonary disease (COPD) -- CONDITION: 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; Small volume nebulizer is medically necessary to administer dornase alfa (Pulmozyme) to members with CF or primary ciliary dyskinesia; Small volume nebulizer is medically necessary to administer epinephrine for the treatment of croup; Small volume nebulizer is medically necessary to administer formoterol (Perforomist) or arformoterol (Brovana) for the management of COPD when medical necessity criteria in the Pharmacy Clinical Policy Bulletin on 'Long-Acting Beta Agonists' are met; Small volume nebulizer is medically necessary to administer treprostinil inhalation solution (Tyvaso) via an ultrasonic pulsed delivery device (the Tyvaso Inhalation System) or iloprost (Ventavis) via a controlled dose inhalation drug delivery system (i.e., the I-neb or the Prodose nebulizer) to members with pulmonary hypertension; Small volume nebulizer is medically necessary to administer mucolytics other than dornase alfa (acetylcysteine) for persistent thick or tenacious pulmonary secretions; Small volume nebulizer is medically necessary to administer pentamidine to members with HIV, pneumocystosis, or complications of organ transplants; Small volume nebulizer is medically necessary to administer colistin for multi-drug resistant P. aeruginosa pneumonia failing to improve on IV therapy; Small volume nebulizer is medically necessary to administer aztreonam inhalation solution (Cayston) to persons with CF with Pseudomonas aeruginosa; The Altera Nebulizer System is medically necessary ONLY to administer aztreonam inhalation solution (Cayston), consistent with FDA-approved labeling requiring this specific device; More than 1 nebulizer may be medically necessary for members who are prescribed nebulized dornase alfa (Pulmozyme) PLUS other nebulized medications, because FDA-approved labeling instructs that dornase alfa should not be diluted or mixed with other drugs in the nebulizer; The Pari-LC Plus Vented Jet Nebulizer is medically necessary for pulmonary administration of aerosolized tobramycin, based on comparative studies showing adequate lung delivery; Large volume nebulizer, related compressor, and water or saline DME to deliver humidity is medically necessary for a person with thick, tenacious secretions when ANY ONE of the following is present: (a) administration of pentamidine for members with HIV, pneumocystosis, and complications of organ transplants; (b) bronchiectasis; (c) cystic fibrosis; (d) tracheobronchial stent; (e) tracheostomy; Ultrasonic nebulizer DME for delivery of tobramycin (TOBI) for members with CF is medically necessary when ALL of the following are met: (1) the member meets the criteria for a standard nebulizer; (2) the primary care physician and specialist indicate that the member has been compliant with other nebulizer and medication therapy; (3) the use of a standard nebulizer has failed to control the member's disease and prevent the member from utilizing the hospital or emergency room; Replacement of nebulizers (for members with DME benefits) is medically necessary on an individual basis when BOTH of the following are met: (1) the primary care physician and/or specialist confirm that the member has been compliant with the nebulizer and anticipate the need for continued use to prevent a hospital admission or emergency room visits; AND (2) the warranty has expired; A battery-powered compressor is rarely medically necessary; accompanying documentation must be submitted justifying its medical necessity; A spring-loaded valve is medically necessary for persons on a ventilator who meet the criteria for a nebulizer; Maximum frequency of accessory replacement considered medically necessary (per item): administration set small volume filtered pneumatic 1/month; administration set small volume non-filtered disposable 2/month; administration set small volume non-filtered non-disposable 1 per 6 months; aerosol mask 1/month; corrugated tubing disposable (large volume) 100 feet per 2 months; corrugated tubing non-disposable (large volume) 10 feet/year; dome and mouthpiece (small volume ultrasonic) 2/year; face tent 1/month; filter disposable (compressor) 2/month; filter non-disposable (compressor/ultrasonic) 1 per 3 months; immersion external heater 1 per 3 years; durable glass or autoclavable plastic bottle-type nebulizer not used with oxygen 1 per 3 years; small volume non-filtered pneumatic nebulizer disposable 2/month; tracheostomy mask or collar 1/month; water collection device (large volume) 2/month. Applies to 22 codes: E0565, E0570, E0572, E0574, E0580, E0585, A7003, A7004, A7005, A7006, A7009, A7010, A7012, A7013, A7014, A7015, A7016, A7017, A7018, 94640, 94642, 94664. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: The plan of care must contain the specific condition of the patient justifying the medical necessity of each item; The order for any drug must clearly specify the type of solution to be dispensed and the administration instructions for that solution; the type of solution is described by a combination of either (1) the name of the drug, the concentration of the drug in the dispensed solution, and the volume of solution in each container, OR (2) the name of the drug, the number of milligrams/grams of drug in the dispensed solution, and the volume of solution in that container; A narrative diagnosis and/or an ICD diagnosis code describing the condition must be present on each order; An ICD code describing the condition that necessitates nebulizer therapy must be included on each claim for equipment, accessories, and/or drugs; The patient's medical record must contain information that supports the medical necessity for all equipment, accessories, drugs, and other supplies that are ordered; For a battery-powered compressor, accompanying documentation must be submitted justifying its medical necessity. Policy exclusions and limitations: The Amnio Breathe Nebulizer is considered experimental, investigational, or unproven; Nebulized corticosteroids for the treatment of nasal polyps, including in the pre- and post-polypectomy periods, are experimental, investigational, or unproven, because of insufficient evidence of clinical value over established forms of nasal corticosteroid administration (e.g., nasal spray, metered-dose nasal inhaler); Nebulized corticosteroids for the prevention and treatment of viral wheezing are experimental, investigational, or unproven; Nebulized heparin for inhalation injury in burn victims is experimental, investigational, or unproven; Nebulized lidocaine for pain relief for nasogastric tube insertion in children is experimental, investigational, or unproven; Nebulized lidocaine for the treatment of chronic cough is experimental, investigational, or unproven; Nebulized magnesium for the treatment of pediatric asthma is experimental, investigational, or unproven; Nebulized sodium nitrite for the treatment of pulmonary hypertension in individuals with beta-thalassemia is experimental, investigational, or unproven; Small volume nebulizers and related compressors are experimental, investigational, or unproven for all indications other than those listed as medically necessary, because effectiveness for other indications has not been established; Large volume nebulizers and related compressors are experimental, investigational, or unproven for all indications other than those listed as medically necessary, because effectiveness for other indications has not been established; Ultrasonic nebulizers are experimental, investigational, or unproven for all indications other than those listed as medically necessary, because effectiveness for other indications has not been established; Use of dornase alfa (Pulmozyme) for non-CF indications (e.g., asthma, chronic bronchitis, Niemann-Pick type C, and post-lung transplantation) is experimental, investigational, or unproven; The Pari-LC Jet Plus brand of nebulizer is NOT medically necessary for nebulization of budesonide inhalation suspension (Pulmicort Respules), because other jet nebulizers deliver effective doses; Ultrasonic nebulizers are not recommended for delivering inhaled budesonide, having been found in clinical studies to be inefficient at delivering it; Breath-enhanced nebulizers have no proven value over conventional jet nebulizers for the treatment of asthma; Kits and concentrates for use in cleaning respiratory equipment are not covered (consistent with Medicare's policy). Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Nebulizers?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: The plan of care must contain the specific condition of the patient justifying the medical necessity of each item; The order for any drug must clearly specify the type of solution to be dispensed and the administration instructions for that solution; the type of solution is described by a combination of either (1) the name of the drug, the concentration of the drug in the dispensed solution, and the volume of solution in each container, OR (2) the name of the drug, the number of milligrams/grams of drug in the dispensed solution, and the volume of solution in that container; A narrative diagnosis and/or an ICD diagnosis code describing the condition must be present on each order; An ICD code describing the condition that necessitates nebulizer therapy must be included on each claim for equipment, accessories, and/or drugs; The patient's medical record must contain information that supports the medical necessity for all equipment, accessories, drugs, and other supplies that are ordered; For a battery-powered compressor, accompanying documentation must be submitted justifying its medical necessity.
What does Aetna exclude for Nebulizers?
Policy exclusions and limitations: The Amnio Breathe Nebulizer is considered experimental, investigational, or unproven; Nebulized corticosteroids for the treatment of nasal polyps, including in the pre- and post-polypectomy periods, are experimental, investigational, or unproven, because of insufficient evidence of clinical value over established forms of nasal corticosteroid administration (e.g., nasal spray, metered-dose nasal inhaler); Nebulized corticosteroids for the prevention and treatment of viral wheezing are experimental, investigational, or unproven; Nebulized heparin for inhalation injury in burn victims is experimental, investigational, or unproven; Nebulized lidocaine for pain relief for nasogastric tube insertion in children is experimental, investigational, or unproven; Nebulized lidocaine for the treatment of chronic cough is experimental, investigational, or unproven; Nebulized magnesium for the treatment of pediatric asthma is experimental, investigational, or unproven; Nebulized sodium nitrite for the treatment of pulmonary hypertension in individuals with beta-thalassemia is experimental, investigational, or unproven; Small volume nebulizers and related compressors are experimental, investigational, or unproven for all indications other than those listed as medically necessary, because effectiveness for other indications has not been established; Large volume nebulizers and related compressors are experimental, investigational, or unproven for all indications other than those listed as medically necessary, because effectiveness for other indications has not been established; Ultrasonic nebulizers are experimental, investigational, or unproven for all indications other than those listed as medically necessary, because effectiveness for other indications has not been established; Use of dornase alfa (Pulmozyme) for non-CF indications (e.g., asthma, chronic bronchitis, Niemann-Pick type C, and post-lung transplantation) is experimental, investigational, or unproven; The Pari-LC Jet Plus brand of nebulizer is NOT medically necessary for nebulization of budesonide inhalation suspension (Pulmicort Respules), because other jet nebulizers deliver effective doses; Ultrasonic nebulizers are not recommended for delivering inhaled budesonide, having been found in clinical studies to be inefficient at delivering it; Breath-enhanced nebulizers have no proven value over conventional jet nebulizers for the treatment of asthma; Kits and concentrates for use in cleaning respiratory equipment are not covered (consistent with Medicare's policy). Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0065 — Nebulizers

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0065 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.