1. (1) The medicaid agency covers, without prior authorization, the purchase of a nebulizer and related compressor, with limits, when the following medicare clinical criteria are met.

   1. (a) Small volume nebulizer and related compressor for the administration of inhalation drugs for:

      1. (i) The management of obstructive pulmonary disease;
      2. (ii) A client with cystic fibrosis or bronchiectasis;
      3. (iii) A client with HIV, pneumocystosis, or complications of organ transplants; or
      4. (iv) Persistent, thick, or tenacious pulmonary secretions.

   2. (b) Large volume nebulizer and related compressor to deliver humidity to a client with thick, tenacious secretions and who has one or more of the following:

      1. (i) Cystic fibrosis;
      2. (ii) Bronchiectasis;
      3. (iii) A tracheostomy; or
      4. (iv) A tracheobronchial stent.
   3. (c) Filtered nebulizer when necessary to administer pentamidine to clients with HIV, pneumocystosis, or complications of organ transplants.

2. (2) The medicaid agency limits payments, per client, as follows:

   1. (a) Compressor - One every five years. Requires thirteen months rental first. After thirteen months, the compressor is considered purchased.
   2. (b) Nebulizer with compressor - One every five years. Reimbursement includes instruction on the proper use and cleaning of the equipment.

3. (3) The medicaid agency pays separately for medically necessary accessories as follows:

   1. (a) Administration set. Purchase only.

      1. (i) With small volume filtered or nonfiltered pneumatic nebulizer, disposable. Limited to one per client every thirty days.
      2. (ii) With small volume nonfiltered pneumatic nebulizer, nondisposable. Limited to one per client every six months.
   2. (b) Aerosol mask, used with nebulizer. Purchase only. Limited to one per client every thirty days.

   3. (c) Corrugated tubing, used with large volume nebulizer. Purchase only.

      1. (i) Disposable, limited to one unit (one hundred feet) per client every sixty days.
      2. (ii) Nondisposable, limited to one unit (ten feet) per client every twelve months.
   4. (d) Face tent. Purchase only. Limited to one per client every thirty days.

   5. (e) Filter. Purchase only.

      1. (i) Disposable, limited to two per client every thirty days.
      2. (ii) Nondisposable, limited to one per client every ninety days.
   6. (f) Large volume nebulizer, disposable, unfilled, used with aerosol compressor. Limited to ten per client every thirty days.
   7. (g) Small volume nonfiltered pneumatic nebulizer, disposable. Purchase only. Limited to two per client every thirty days.
   8. (h) Tracheostomy mask, each. Purchase only. Limited to four per client every thirty days.
   9. (i) Heated humidifier with temperature monitor and alarm for clients who have a tracheostomy but who are not ventilator dependent. Monthly rental only. Prior authorization is required.
   10. (j) Water collection device, used with large volume nebulizer. Purchase only. Limited to eight per client every thirty days.
   11. (k) Water, distilled, used with large volume nebulizer, 1000 ml. Limited to fifty units per client every thirty days.
   12. (l) Immersion external heater for a nebulizer. Purchase only. Prior authorization is required.
4. (4) Providers must monitor the amount of supplies and accessories a client is actually using and assure that the client has nearly exhausted the supply on hand prior to dispensing any additional items.
5. (5) The medicaid agency does not pay for a large volume nebulizer, related compressor/generator, and water or saline when used predominantly to provide room humidification.

[Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0650, filed 6/25/12, effective 8/1/12.]