Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
The rules say that A small volume nebulizer (A7003, A7004, A7005), and related compressor (E0570) are 
considered for coverage when it is reasonable and necessary to administer the following FDA-approved 
inhalation solutions listed below: 
a. It is reasonable and necessary to administer albuterol (J7611, J7613), arformoterol (J7605), budesonide 
(J7626), cromolyn (J7631), formoterol (J7606), ipratropium (J7644), levalbuterol (J7612, J7614), 
metaproterenol (J7669), or revefenacin (J7677) for the management of obstructive pulmonary disease 
(refer to the Group 8 Codes in the LCD-related Policy Article for applicable diagnoses); or 
b. It is reasonable and necessary to administer dornase alfa (J7639) to a beneficiary with cystic fibrosis 
(refer to the Group 9 Codes in the LCD-related Policy Article for applicable diagnoses); or 
c. It is reasonable and necessary to administer tobramycin (J7682) to a beneficiary with cystic fibrosis or 
bronchiectasis (refer to the Group 10 Codes in the LCD-related Policy Article for applicable diagnoses); 
or 
d. It is reasonable and necessary to administer pentamidine (J2545) to a beneficiary with HIV, 
pneumocystosis, or complications of organ transplants (refer to the Group 4 Codes in the LCD-related 
Policy Article for applicable diagnoses); or 
e. It is reasonable and necessary to administer acetylcysteine (J7608) for persistent thick or tenacious 
pulmonary secretions (refer to the Group 7 Codes in the LCD-related Policy Article for applicable 
diagnoses). 
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. You can find this information in the Local 
Coverage Determination (LCD) Nebulizers L33370. 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.