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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
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:
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.
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.
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.