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Lung volume reduction surgery (LVRS) is proposed as a treatment option for patients with severe emphysema who have failed optimal medical management. The procedure involves the excision of diseased lung tissue and aims to reduce symptoms and improve quality of life.
Lung volume reduction is a surgical treatment for patients with severe emphysema involving the excision of peripheral emphysematous lung tissue, generally from both upper lobes. The precise mechanism of clinical improvement for patients undergoing lung reduction surgery has not been firmly established. However, it is believed that elastic recoil and diaphragmatic function are improved by reducing the volume of diseased lung. In addition to changes in chest wall and respiratory mechanics, the surgery is purported to correct ventilation perfusion mismatch and improve right ventricular filling.
Research on LVRS has focused on defining the subgroup of patients most likely to benefit from the procedure. Potential benefits of the procedure (eg, improvement in functional capacity and quality of life) must be weighed against the potential risk of the procedure (eg, risk of postoperative mortality).
POLICYLung volume reduction surgery as a treatment for emphysema may be considered medically necessary in patients with emphysema who meet ALL of the following criteria*:
Lung volume reduction surgery is considered investigational in all other patients.
*Patient selection criteria are based on the National Emphysema Treatment Trial (NETT).
For Federal Employee Program (FEP) subscribers only, lung volume reduction surgery as a treatment for emphysema may be considered medically necessary in patients with emphysema who meet ALL criteria and investigational for all other patients. (See FEP policy) (added 3-25-2004)
POLICY GUIDELINESThe following additional criteria, also from the NETT trial, may provide further information in determining whether a patient is a candidate for lung volume reduction surgery:
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY5/1999: Approved by Medical Policy Advisory Committee (MPAC)
2/14/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
8/15/2002: “There is no specific CPT code for this procedure” added to the Code Reference section
3/2004: Reviewed by MPAC, investigational status maintained, Policy title “Lung Volume Reduction Surgery for COPD due to Emphysema” renamed “Lung Volume Reduction Surgery for Severe Emphysema”, Description section revised to be consistent with BCBSA policy # 7.01.71, FEP exception added, Sources updated, non-covered table added to Code Reference section and “All codes billed for this investigational procedure are not covered. There is no specific CPT code for this procedure.” deleted
4/29/2004: Code Reference section completed
10/23/2006: Policy reviewed, medically necessary for emphysema within guidelines as noted
10/30/2006: Code Reference section updated. Non-covered table changed to covered table. ICD-9 diagnosis code 492.8 added to table.
07/08/2010: Policy description unchanged. Policy statement revised to add the time frame of "at least 4 months" abstinence from cigarette smoking. Patient selection criteria added to the policy guidelines.
08/23/2011: Policy statement revised regarding FEV criteria. Changed from "FEV-1 between 20% and 35% of predicted" to "Forced expiratory volume in one second (FEV-1) less than 45% predicted for patients age 70 or younger and greater than 15% predicted for patients over age 70." Deleted outdated references from the Sources section.
07/17/2012: Policy reviewed; no changes.
10/23/2013: Policy reviewed; no changes.
08/08/2014: Policy reviewed; description updated. Medically necessary policy statement criteria for FEV-1 revised to state the following: (1) For patients who are younger than 70 years of age, the FEV-1 must be no more than 45% of the predicted value. (2) For patients who are 70 years of age or older, the FEV-1 must be no more than 45% of the predicted value and 15% or more of the predicted value. It previously stated: Forced expiratory volume in one second (FEV-1) less than 45% predicted for patients age 70 or younger and greater than 15% predicted for patients over age 70.
08/31/2015: Code Reference section updated for ICD-10.
10/19/2015: Policy guidelines section updated to add medically necessary and investigative definitions.
SOURCE(S)Blue Cross Blue Shield Association policy # 7.01.71
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.