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December 2016 Texas Medicaid Provider Procedures Manual

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook : 2 Texas Medicaid (Title XIX) Home Health Services : 2.2 Services, Benefits, Limitations and Prior Authorization : 2.2.19 Respiratory Equipment and Supplies : Nebulizers
Nebulizers may be reimbursed for purchase only, and that purchase is limited to 1 every 5 years. Providers must use procedure code E0570 when billing for the purchase of the nebulizer.
For fee-for-service, medications that are used with the nebulizer will not be reimbursed to a DME company. These medications may be considered under the Vendor Drug Program.
Refer to:
Nebulizers and nebulizer supplies do not require prior authorization for the diagnoses listed below. Other diagnoses require prior authorization and may be considered based on review of documentation by HHSC or its designee.
Purchase of nebulizers may be considered for prior authorization for diagnoses other than those listed in the diagnosis table for nebulizers, with documentation of medical necessity.
The following procedure codes for nebulizer supplies may be billed with the diagnosis codes listed above:
Ultrasonic nebulizers may be considered for prior authorization for the following diagnoses with documentation for failure of standard therapy:
Providers must use procedure code A7009, A7014, or A7016 when billing supplies with an ultrasonic nebulizer.
Providers must include documentation by the physician who is familiar with the client that the client is compliant with the use of the equipment and that the treatment is effective.

Texas Medicaid & Healthcare Partnership
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