A4627 — Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- The NHLBI Expert Panel Report guidelines on asthma management recommend that the physician gives the patient written instructions on interpreting the peak flow meter (such as what levels are acceptable, what levels require use of inhalers or other treatments, and what levels indicate that one should seek emergency care).
- No explicit claim-submission documentation requirements (e.g., required test results, forms, or prior authorization language) are specified in this policy document beyond the general statement that HCPCS codes are covered 'if selection criteria are met.'
Key Coverage Criteria
- HCPCS codes covered if selection criteria are met: S8100 Holding chamber or spacer for use with an inhaler or nebulizer; without mask
- HCPCS codes covered if selection criteria are met: S8097 Asthma kit (including but not limited to portable peak expiratory flow meter, instructional video, brochure, and/or spacer)
- Aetna considers standard mechanical peak flow meters and spacers for metered-dose inhalers medically necessary durable medical equipment (DME) for members with asthma, bronchitis, emphysema, or other obstructive pulmonary conditions.
- HCPCS codes covered if selection criteria are met: A4614 Peak expiratory flow rate meter, hand held
- HCPCS codes covered if selection criteria are met: A4627 Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler
- HCPCS codes covered if selection criteria are met: S8096 Portable peak flow meter
1 Active Policy
AETNA-CPB-0059 — Peak Flow Meters
Related Codes
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