Nebulizers - DME.O2.104.A

EviCore covers small-volume nebulizers (E0570) for prescribed nebulized medications; standard large-volume nebulizers (E0572/E0565/E0585) for humidification in patients with thick, tenacious secretions who have bronchiectasis, cystic fibrosis, tracheostomy, or a tracheobronchial stent (and for pentamidine administration in HIV, pneumocystosis, or post‑transplant with complications); ultrasonic small (E0574) and controlled-dose systems (K0730) are covered only for treprostinil and iloprost delivery respectively, ultrasonic large (E0575) is covered only after failure of a standard large-volume device, while pre-filled disposable large-volume nebulizers (A7008) and routine home nebulizer use for asthma/COPD are generally not medically necessary. Key requirements: documentation of the qualifying diagnosis and thick, tenacious secretions where applicable, prescription/medical necessity for the specific medication/device (including treprostinil/iloprost), evidence of prior failure of standard devices for E0575, and clinical justification for nebulizer use over pMDI/DPI; accessories are payable only if necessary for a covered compressor.