I'm a provider

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.

Lung volume reduction surgery is palliative not curative. The procedure is designed to relieve dyspnea and improve functional capacity and quality of life. Patients continue to have severe emphysema, and most patients will show further progression of their disease over time.

• Predominantly upper lobe emphysema with hyperinflation and heterogeneity (i.e., target areas for removal)
• 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
• Marked restriction in activities of daily living despite maximal medical therapy
• Age younger than 75 years
• Acceptable nutrition status; i.e., 70%–130% of ideal body weight
• Ability to participate in a vigorous pulmonary rehabilitation program
• No coexisting major medical problems that would significantly increase operative risk
• Willingness to undertake risk of morbidity and mortality associated with LVRS
• Abstinence from cigarette smoking for at least 4 months

Lung volume reduction surgery is considered investigational in all other patients.

*patient selection criteria are based on the National Emphysema Treatment Trial

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)

• PaO2 on room air greater than or equal to 45mm Hg (greater than or equal to 30mm Hg at elevations of 5,000 feet or higher)
• PaCO2 on room air less than or equal to 60mm Hg (less than or equal to 55mm Hg at elevations of 5,000 feet or higher)
• Post-rehabilitation 6-minute walk of at least 140 m, and able to complete 3 min. unloaded pedaling in exercise tolerance test

Investigative 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.

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.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.  

Covered Codes

Top