Electromagnetic Navigational Bronchoscopy (ENB)

Policy ID: M-85-003

Section: Diagnostic Medical

Effective Date: January 04, 2021

Revised Date: October 10, 2022

Revision Effective Date: January 02, 2022

Last Reviewed: November 15, 2023

Applies To: Commercial and Medicaid Expansion

Description

Electromagnetic navigation bronchoscopy (ENB) is intended to enhance standard bronchoscopy by providing a three-dimensional roadmap of the lungs and real-time information about the position of the steerable probe during bronchoscopy. The purpose of ENB is to allow navigation to distal regions of the lungs, so that suspicious lesions can be biopsied and to allow fiducial markers placement.

Criteria

When flexible bronchoscopy alone, or with endobronchial ultrasound, is considered inadequate to accomplish the diagnostic or interventional objective, electromagnetic navigation bronchoscopy (ENB) may be considered medically necessary to:

Establish a diagnosis of suspicious peripheral pulmonary lesion(s) or
To place fiducial markers within lung tumor(s) prior to treatment.

Electronic navigational bronchoscopy not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

31626

31627

A4648

Outpatient HCPCS (C Codes)

C9751

Diagnosis Codes

C34.00

C34.01

C34.02

C34.11

C34.12

C34.30

C34.31

C34.32

C34.80

C34.81

C34.82

C34.90

C34.91

C34.92

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

Internal Medical Policy Committee 11-29-2022 Revision

Updated with clarifying language

Internal Medical Policy Committee 11-15-2023-Annual Review no changes in criteria

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: M-85-002

Section: Diagnostic Medical

Effective Date: January 04, 2021

Last Reviewed: November 23, 2021

Archived Date: January 01, 2023

Applies To: Commercial and Medicaid Expansion

Description

Electromagnetic navigation bronchoscopy (ENB) is intended to enhance standard bronchoscopy by providing a three (3)- dimensional roadmap of the lungs and real-time information about the position of the steerable probe during bronchoscopy. The purpose of ENB is to allow navigation to distal regions of the lungs, so that suspicious lesions can be biopsied and to allow fiducial markers placement.

Criteria

Establish a diagnosis of suspicious peripheral pulmonary lesion(s) or
To place fiducial markers within lung tumor(s) prior to treatment.

Electronic navigational bronchoscopy 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

31626

31627

A4648

C9751

Diagnosis Codes

C34.00

C34.01

C34.02

C34.11

C34.12

C34.30

C34.31

C34.32

C34.80

C34.81

C34.82

C34.90

C34.91

C34.92

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

Links

References (PDF)

Disclaimer

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