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Issue Number - Name
0026 - Nebulizers- Medical Necessity
Review Type
Complex
Claim Type
DME by Supplier and DME by Provider
Region and State
RAC 5
All States
Date Approved
2017-04-11

Description

Documentation will be reviewed to determine if the Nebulizer Related Drugs meet Medicare coverage criteria validate the drug dosage dispensed versus dosage billed.

Affected Codes

  • J2545, J7605, J7606, J7608, J7611, J7612, J7613, J7614, J7626, J7631, J7639, J7644, J7669, J7682, J7686, Q0474, J7620

Applicable Policy References 

  • CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 200.2
  • CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 280.1 
  • CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 20, Section 100
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2
  • Nationwide LCD, L33370, Effective Date 10/01/2015
  • CGS LCD, L5007, Effective Date 04/01/1997, Retired 09/30/2015
  • NGS LCD, L27226, Effective Date 04/01/1997, Retired 09/30/2015
  • Noridian LCD, L11488, Effective Date 04/01/1997, Retired 09/30/2015  
  • NHIC LCD, L11499, Effective Date 04/01/1997, Retired 09/30/2015
  • Nationwide Article, A52466, Effective Date 10/01/2015
  • NHIC Article, A24944, Effective Date 04/01/2005, Retired 09/30/2015  
  • NGS Article, A47233, Effective Date 04/01/2005, Retired 09/30/2015
  • Noridian Article, A24942, Effective Date 04/01/2005, Retired 09/30/2015
  • CGS Article, A24623, Effective Date 04/01/2005, Retired 09/30/2015
  • LCD, A55426, Effective Date 01/01/2017