Endobronchial Valve Surgery

Policy ID: S-268-003

Section: Surgery

Effective Date: January 04, 2021

Revised Date: July 09, 2024

Revision Effective Date: September 02, 2024

Last Reviewed: July 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

Bronchial valves are synthetic devices deployed with bronchoscopy into ventilatory airways of the lung to control airflow. They have been investigated for use in individuals who have prolonged bronchopleural air leaks and in individuals with lobar hyperinflation from severe or advanced emphysema.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Endobronchial valve surgery may be considered medically necessary when ALL of the following are met:

Endobronchial valves are approved by the United States Food and Drug Administration; and
For the treatment of hyperinflation related to severe or very severe emphysema or COPD; and
In regions of the lung that have little to no collateral ventilation.

Endobronchial valve surgery not meeting the criteria as indicated in this policy is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

31647

31648

31649

31651

Classification of severity of airflow obstruction

Stages of Airflow Limitation

Severity Grouping

GOLD 1 ( mild ): FEV1 greater than or equal to ( >) 80% predicted

Group A: low risk

0-1 exacerbation per year, not requiring hospitalization, fewer symptoms

GOLD 1 ( moderate ):

50% less than or equal to ( <) FEV1 less than (<)80% predicted

Group B: low risk

One (1) exacerbation per year, not requiring hospitalization, more symptoms

GOLD 3 ( severe ):

30% less than or equal to ( <) FEV1 less than (<)50% predicted

Group C: high risk

Greater than or equal to (>) two (2) exacerbations per year, or one (1) or more requiring hospitalization, fewer symptoms

GOLD 3 ( verysevere ):

FEV1 less than (<) 30% predicted

Group D: high risk

Greater than or equal to (>) two (2) exacerbations per year, or one (1) or more requiring hospitalization, more symptoms

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 31647, 31648, 31649, and 31651

J43.0

J43.1

J43.2

J43.8

J43.9

J44.0

J44.1

J44.9

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-2020 New Policy

Internal Medical Policy Committee 11-23-2021 Annual Review, no changes in criteria

Internal Medical Policy Committee 01-20-2022 Coding update- Effective March 03, 2022

Added Diagnosis codes J44.0; J44.1; J44.9

Internal Medical Policy Committee 07-16-2024 Revision - Effective September 02, 2024

Updated language; and
Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-268-002

Section: Surgery

Effective Date: January 04, 2021

Revised Date: December 10, 2021

Revision Effective Date: March 07, 2022

Last Reviewed: January 20, 2022

Archived Date: September 01, 2024

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Endobronchial valves that are approved by the United States Food and Drug Administration (U.S. FDA) (i.e., the Spiration Valve System and Zephyr Valve System) may be considered medically necessary for the treatment of adult individuals with hyperinflation related to severe or very severe emphysema in regions of the lung that have little to no collateral ventilation.

Endobronchial valve not meeting the criteria as indicated in this policy is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

31647

31648

31649

31651

Classification of severity of airflow obstruction

Stages of Airflow Limitation

Severity Grouping

GOLD 1 (mild): FEV1> 80% predicted

Group A: low risk

0-1 exacerbation per year, not requiring hospitalization, fewer symptoms

GOLD 1 (moderate):

50% < FEV1 <80% predicted

Group B: low risk

One (1) exacerbation per year, not requiring hospitalization, more symptoms

GOLD 3 (severe):

30% < FEV1 <50% predicted

Group C: high risk

> two (2) exacerbations per year, or one (1) or more requiring hospitalization, fewer symptoms

GOLD 3 (very severe):

FEV1 <30% predicted

Group D: high risk

> two (2) exacerbations per year, or one (1) or more requiring hospitalization, more symptoms

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 31647, 31648, 31649, and 31651

J43.0

J43.1

J43.2

J43.8

J43.9

J44.0

J44.1

J44.9

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-2020 New Policy

Internal Medical Policy Committee 11-23-2021 Annual Review, no changes in criteria

Internal Medical Policy Committee 01-20-2022 Coding update-Effective March 03, 2022

Added Diagnosis codes J44.0; J44.1; J44.9

Links

References (PDF)

Disclaimer

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