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DESCRIPTIONPulmonary nodules are identified on plan chest x-rays or chest computed tomography (CT) scans. (Note: Screening for lung cancer and whole-body CT scans for screening are considered investigational.) Although most of these nodules are benign, some are cancerous and early diagnosis of lung cancer is desirable because of the poor prognosis when cancer is diagnosed later in the disease course. The method used to diagnosis lung cancer depends on a number of factors, including lesion size and location, as well as the clinical history and status of the patient. There is generally greater diagnostic success with centrally located and larger lesions.
Peripheral lung lesions and solitary pulmonary nodules (SPN) (which are most often defined as asymptomatic nodules less than 6mm) are more difficult to evaluate than larger, centrally located lesions. There are several options for diagnosing them; none of the methods are ideal for safely and accurately diagnosing malignant disease. Sputum cytology is the least invasive approach. Reported sensitivity rates are relatively low and vary widely across studies; sensitivity is lower for peripheral lesions. Sputum cytology, however, has a high specificity and a positive test may obviate the need for more invasive testing.
Flexible bronchoscopy, a minimally invasive procedure, is an established approach to evaluating pulmonary nodules. The sensitivity of flexible bronchoscopy for diagnosing bronchogenic carcinoma has been estimated at 88 percent for central lesions and 78 percent for peripheral lesions. For small peripheral lesions, less than 1.5 cm in diameter, the sensitivity may be as low as 10 percent. The diagnostic accuracy of transthoracic needle aspiration for solitary pulmonary nodules tends to be higher than that of bronchoscopy. The sensitivity and specificity are both approximately 94 percent. A disadvantage of transthoracic needle aspiration is that a pneumothorax develops in 11 - 24 percent of patients and 5 - 14 percent require insertion of a chest tube. PET scans are also highly sensitive for evaluating pulmonary nodules, yet may miss small lesions less than 1 cm in size. Lung biopsy is the gold standard for diagnosing pulmonary nodules, but is an invasive procedure.
Recent advances in technology have led to enhancements that may increase the yield of established diagnostic methods. CT scanning equipment can be used to guide bronchoscopy and bronchoscopic transbronchial needle biopsy, but have the disadvantage of exposing the patient and staff to radiation. Endobronchial ultrasound (EBUS) by radial probes, previously used in the perioperative staging of lung cancer, can also be used to locate and guide sampling of peripheral lesions. EBUS is reported to increase the diagnostic yield of flexible bronchoscopy to at least 82 percent, regardless of the size and location of the lesion.
Another proposed enhancement to standard bronchoscopy is Electromagnetic Navigation Bronchoscopy (ENB) using the InReachTM System. This technology uses CT scans to improve the ability of standard bronchoscopic procedures to reach lesions in the periphery of the lungs. There are three phases of a procedure using the InReachTM System, as follows:
In September 2004, the superDimension/Bronchus (superDimension Ltd, Herzliya, Israel) was cleared for marketing by the Food and Drug Administration (FDA) through the 510(k) process. The FDA determined that this device was substantially equivalent to existing bronchoscopic devices. It is indicated for displaying images of the tracheopbronchial tree that aids physicians in guiding endoscopic tools in the pulmonary tract. The device is not intended as an endoscopic tool, does not make a diagnosis and is not approved for pediatric use. The trade name of the device is the InReachTM System; it is currently marketed in the United States by superDimension, Inc., Minneapolis, MN.
POLICYElectromagnetic navigation bronchoscopy is considered investigational for use with flexible bronchoscopy for the diagnosis of pulmonary lesions and mediastinal lymp nodes.
Electromagnetic navigation bronchoscopy is considered investigational for the placement of fiducial markers.
POLICY EXCEPTIONSFederal Employee Program may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such; therefore, is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.
POLICY HISTORY04/16/2010: New policy added.
04/25/2011: Policy statement revised to state that electromagnetic navigation bronchoscopy is considered investigational for the placement of fiducial markers.
03/02/2012: Policy reviewed; no changes.
04/04/2013: Policy reviewed; no changes.
SOURCESBlue Cross Blue Shield Association Policy # 7.01.122
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.