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A.7.01.71
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 to reduce symptoms and improve quality of life.
Emphysema
Emphysema is an anatomically defined condition characterized by the destruction and enlargement of lung alveoli. It is one of the conditions considered as a chronic obstructive pulmonary disease along with chronic bronchitis and small airway disease. The pathogenesis of emphysema is primarily related to cigarette smoking leading to inflammation and recruitment of immune cells to the terminal air spaces of the lung. The resultant extracellular matrix proteolysis damages the lung. Destruction of the gas-exchanging air spaces and ineffective repair of the extracellular matrix results in airspace enlargement. Emphysema can be characterized into distinct pathologic subtypes. Centriacinar emphysema is most frequently associated with cigarette smoking, is usually most prominent in the upper lobes and superior segments of the lower lobes, and is focal. Panacinar emphysema is characterized by abnormally large air spaces evenly distributed across acini in the lower lobes. It is associated with α1-antitrypsin deficiency. Key pulmonary function parameters are the volume of the first forced expiratory volume in 1 second (FEV1) and the total volume of air exhaled during the spirometry (forced vital capacity [FVC]). Airflow obstruction related to chronic obstructive pulmonary disease is characterized by the reduced ratio of FEV1/FVC, and reduction in FEV1 correlates with long-term mortality risk.
The 2023 Global Initiative for Chronic Obstructive Lung Disease (GOLD) report states that chronic obstructive pulmonary disease is 1 of the top 3 causes of death globally and 90% of these deaths occur in low- and middle-income countries. Evidence exists that the prevalence of the disease is appreciably higher in smokers and ex-smokers compared to non-smokers, in those ≥40 years of age compared to those <40, and in men compared to women. Although in developed countries with less smoking, the prevalence is approximately equal between men and women. The COPD Genetic Epidemiology (COPDGene®) study aimed to determine the influence of race, gender, and GOLD stage on the prevalence of prior COPD diagnosis at enrollment. Results revealed that African-American individuals had increased odds of not having a prior COPD diagnosis at all GOLD stages of airflow obstruction versus non-Hispanic White individuals (p<.0001). Women had higher odds of having a prior COPD diagnosis at all GOLD stages versus men (p<.0001).
Lung Volume Reduction Surgery
Lung volume reduction is a surgical treatment for patients with severe emphysema. Lung volume reduction surgery can be performed using several surgical approaches to access the lungs including median sternotomy, video-assisted thoracoscopic surgery, and thoracotomy. The procedure involves the excision of peripheral emphysematous lung tissue, generally from both upper lobes.
The mechanism of clinical improvement for patients undergoing lung reduction surgery has not been firmly established. However, it is believed that mechanical factors such as elastic recoil and diaphragmatic function are improved by reducing the volume of the hyperinflated diseased lung. In addition to changes in the chest wall and respiratory mechanics, the surgery is purported to correct ventilation-perfusion mismatch and improve right ventricular filling.
Complications from the surgical procedure include death, reintubation, arrhythmias, mechanical ventilation for more than 2 days, pneumonia, wound infection, and persistent air leak.
Research on lung volume reduction surgery 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 risks of the procedure (eg, risk of postoperative mortality).
A related policy regarding the Bronchial Valves , evaluates the use of endobronchial valves for patients with severe or advanced emphysema. Both lung volume reduction surgery and endobronchial valves aim to reduce hyperinflation in patients with emphysema, but they differ in invasiveness and delivery. Bronchial valves are a synthetic one-way valve inserted via bronchoscopy into the most diseased lobe of the lung, allowing air to escape but preventing its re-entry. This process results in volume reduction of the treated lobe, potentially improving lung function and quality of life for selected patients.
Lung volume reduction surgery is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.
Lung volume reduction surgery as a treatment for emphysema may be considered medically necessary in individuals who meet ALL of the following criteria*:
Predominantly upper-lobe emphysema with hyperinflation and heterogeneity (i.e., target areas for removal);
Forced expiratory volume in one second (FEV1):
For individuals who are younger than 70 years of age, the FEV1 must be no more than 45% of the predicted value.
For individuals who are 70 years of age or older, the FEV1 must be no more than 45% of the predicted value and 15% or more of the predicted value.
Marked restriction in activities of daily living, despite maximal medical therapy;
Age younger than 75 years;
Acceptable nutrition status (i.e., 70% to 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 lung volume reduction surgery;
Abstinence from cigarette smoking for at least 4 months.
Lung volume reduction surgery is considered investigational in all other individuals.
*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)
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
The following additional criteria, also from the National Emphysema Treatment Trial, may further refine the selection of an individual who is a candidate for lung volume reduction surgery:
Arterial partial pressure of oxygen on room air of 45 mm Hg or more (greater than or equal to 30 mm Hg at elevations of 5,000 feet or higher [1524 meters])
Arterial partial pressure of carbon dioxide on room air less than or equal to 60 mm Hg (less than or equal to 55 mm Hg at elevations of 5,000 feet or higher [1524 meters])
Post-rehabilitation 6-minute walk distance of at least 140 meters, and ability to complete 3 minutes of unloaded pedaling in exercise tolerance test.
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 Mental Health Disorders, 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 medical necessity, “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.
5/1999: 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.
05/31/2016: Policy number A.7.01.71 added.
08/18/2016: Policy description updated regarding FDA regulation. Policy statements unchanged.
07/17/2017: Policy description updated regarding emphysema. Policy statements unchanged.
09/06/2018: Policy description updated regarding lung volume reduction surgery. Policy statements unchanged. Policy Guidelines updated regarding criteria for determining whether a patient is a candidate for lung volume reduction surgery.
07/16/2019: Policy reviewed; no changes.
07/15/2020: Policy reviewed. Policy statements unchanged. Policy Guidelines updated.
08/26/2021: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."
07/15/2022: Policy description updated regarding chronic obstructive pulmonary disease. Policy statements and Policy Guidelines updated to change "patients" to "individuals."
10/05/2023: Policy description updated. Policy statements unchanged.
07/24/2024: Policy description updated regarding lung volume reduction surgery. Policy statements unchanged.
08/26/2025: Policy description updated regarding lung volume reduction surgery. Policy statements unchanged.
Blue Cross Blue Shield Association policy # 7.01.71
This 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.
Code Number | Description | ||
CPT-4 | |||
32491 | Removal of lung, other than total pneumonectomy; excision-plication of emphysematous lung(s) (bullous or non-bullous) for lung volume reduction, sternal split or transthoracic approach, with or without any pleural procedure | ||
HCPCS | |||
ICD-9 Procedure | ICD-10 Procedure | ||
32.22 | Lung volume reduction surgery | 0BBK0ZZ, 0BBK3ZZ, 0BBK7ZZ, 0BBL0ZZ, 0BBL3ZZ, 0BBL7ZZ, 0BBM0ZZ, 0BBM3ZZ, 0BBM7ZZ | Excision of a section of the lung, by approach |
ICD-9 Diagnosis | ICD-10 Diagnosis | ||
492.8 | Other emphysema | J43.0 - J43.9 | Emphysema (code range) |
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