DME MACs Issue Nebulizer Guidance

NASHVILLE, Tennessee—The Durable Medical Equipment Medical Administrative Contractors (DME MACs) have released a joint publication reminder in response to questions on drug coverages for nebulizers and external infusion pump local coverage determinations (LCDs).

“Suppliers are reminded that while these LCDs are often thought of as a drug coverage policy, the benefit is durable medical equipment (DME) and the inhaled or infused drug is considered as a supply to the DME,” the joint publication said. “Consequently, the overarching coverage requirement is that administration of the drug via a nebulizer or external infusion pump must be reasonable and necessary.”

The nebulizer and external infusion pump LCDs outline the coverage criteria for specific drugs or classes of drugs that meet the requirements for coverage, the reminder goes on to say. 

“Coverage details for newly approved drugs will not initially be available within the LCDs until a reconsideration is completed and evaluated by the DME MACs. In such situations, claims for drugs are processed on a claim-by-claim basis. ‘Clean’ claims for miscellaneous codes or not otherwise classified codes are subject to the same claim processing timeliness standards as other HCPCS codes,” it reads. 

The reminder includes guidelines for what information providers should include on claims, as well as additional information for drugs and pump when submitting claims.