Endobronchial Valve Surgery

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

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.

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

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-268-001

Section: Surgery

Effective Date: January 04, 2021

Last Reviewed: November 23, 2021

Archived Date: March 06, 2022

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Endobronchial valves that are approved by the Food and Drug Administration (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’s for any other indication 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, 31651, 31648, and 31649

J43.0

J43.1

J43.2

J43.8

J43.9

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

Links

References (PDF)

Disclaimer

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