Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.30
    OpenPayerPolicy UpdatesPulmonologyAetna EN-guided Bronchoscopy Coverage Update | Ope…
    Ask Trek AI about this page

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    CurrentAetnaPolicy 0776

    Electromagnetic Navigation-Guided Bronchoscopy

    Customize your policy alerts

    Sign up for Aetna Policy 0776 alerts

    Get alerted when Policy 0776 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Clinical policy governing medical necessity, coverage, and investigational status of electromagnetic navigation-guided bronchoscopy for diagnosis and related uses in members covered by Aetna.

    Policy Summary
    PayerAetna
    PolicyElectromagnetic Navigation-Guided Bronchoscopy
    Policy CodePolicy 0776
    Change TypeNo material changes
    Effective DateFeb 6, 2009
    Last ReviewOct 26, 2023
    Next Review DateAug 22, 2024
    Key ActionObtain prior authorization and submit documentation that the peripheral pulmonary nodule is not accessible by standard bronchoscopy or transthoracic biopsy and that selection criteria for medical necessity are met.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    medically necessaryPrimary covered indication
    ≈62–74%Reported diagnostic yield
    0–7.5%Pneumothorax risk
    73%NAVIGATE 12-mo yield
    ≈65%Average diagnostic yield

    Coverage Criteria - Electromagnetic Navigation-guided Bronchoscopy (ENB)

    Medical Necessity - EN-guided bronchoscopy

    Covered when ALL of the following are met:

    Primary coverage criteria: Individual has a peripheral pulmonary nodule that requires a pathologic diagnosis and is not accessible by standard bronchoscopy methods or by a transthoracic biopsy approach.

    From Medical Necessity statement.

    Experimental and Investigational

    Not covered / considered experimental and investigational:

    Experimental or investigational procedures: Cone-beam CT augmented EN-guided bronchoscopy for biopsy of indeterminate pulmonary nodules; EN bronchoscopy-guided microwave ablation for the treatment of pulmonary nodules; Trans-bronchial lung cryo-biopsy for improvement of diagnostic yield of digital tomosynthesis-assisted EN-guided bronchoscopic biopsy of pulmonary nodules.

    Listed as experimental/investigational due to insufficient evidence.

    Policy Summary
    PayerAetna
    PolicyElectromagnetic Navigation-Guided Bronchoscopy
    Policy CodePolicy 0776
    Change TypeNo material changes
    Effective DateFeb 6, 2009
    Last ReviewOct 26, 2023
    Next Review DateAug 22, 2024
    Key ActionObtain prior authorization and submit documentation that the peripheral pulmonary nodule is not accessible by standard bronchoscopy or transthoracic biopsy and that selection criteria for medical necessity are met.
    SourceLink
    On This Page
    Coverage Criteria - Electromagnetic Navigation-guided Bronchoscopy (ENB)Coding and Billing GuidanceProvider Actions, Prior Authorization, and DocumentationBackground and Clinical ContextDefinitions and Study Descriptions

    Situations supporting use of ENB

    Clinical evidence and circumstances in which ENB is used or considered (supporting coverage when documentation shows ALL relevant clinical factors):

    ENB candidate criteria: Operator documents that ENB is chosen because: (1) the pulmonary lesion is peripheral or difficult to access by conventional bronchoscopy; (2) lesion characteristics, comorbidity, or prior failed diagnostic attempts make TTNA or surgical biopsy higher risk; (3) need for fiducial placement, dye marking, or combined diagnostic/therapeutic procedure; and (4) plan for obtaining adequate tissue for histologic and molecular testing when indicated.

    Synthesis from guidelines and NAVIGATE cohort evidence.

    Comparative evidence caveats

    Factors that may argue against ENB or that require justification when opting for ENB instead of alternatives:

    Comparative limitation: Comparative evidence indicates ENB-guided biopsy has lower diagnostic yield than CT-guided TTNA (but lower pneumothorax rates); variable yields across studies (approximately 44–75%, average ~65%) and lack of definitive randomized trials require documentation of why ENB is preferred for this patient.

    Based on NICE assessment, UpToDate and guideline summaries.

    Specific EN-guided procedures are identified in the policy as experimental and investigational. These explicitly include: cone-beam CT (CBCT) augmented EN-guided bronchoscopy for biopsy of indeterminate pulmonary nodules; EN bronchoscopy-guided microwave ablation for treatment of pulmonary nodules; and trans-bronchial lung cryo-biopsy when used to improve the diagnostic yield of digital tomosynthesis–assisted EN-guided bronchoscopic biopsy. These approaches are listed as investigational because effectiveness has not been established.

    The document does not list additional explicit exclusions beyond the investigational procedures named elsewhere. NICE (2019) is cited to note that comparative evidence finds ENB has lower diagnostic yield than CT-guided TTNA but lower pneumothorax rates, and that the role of ENB among other guided bronchoscopy techniques is not yet established — indicating that further evidence is needed before broader adoption or definitive placement within diagnostic pathways.

    When EN-guided bronchoscopy is combined with cone-beam CT, the policy highlights resource and radiation implications. CBCT-equipped procedure rooms are costly and require additional staff training, and CBCT use exposes patients to additional radiation (average ~3.5 CBCT spins per procedure reported). If the additional radiation exposure cannot be justified and discussed with the patient, this may be a basis for limiting use or for denial of the combined CBCT-augmented approach.

    Available assessments and guidelines indicate that data are insufficient to show ENB reliably avoids surgical biopsy in patients who are surgical candidates. A VA technology assessment concluded that low negative predictive value limits confidence that ENB can replace surgical biopsy, so ENB should not be relied on to avoid indicated surgical procedures in those candidates.

    This policy segment does not use explicit 'not medically necessary' wording for ENB in general; however, comparative evidence limitations are emphasized. Because ENB often has lower diagnostic yield than CT-guided transthoracic needle aspiration and randomized superiority data are lacking, the absence of documented justification for choosing ENB over an appropriate alternative (e.g., CT-guided biopsy when feasible) may result in non-coverage or denial when the selection criteria are not met.

    Coding and Billing Guidance

    Covered CPT Codes (if selection criteria met)CPTCovered
    31627Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with computer-assisted, image-guided navigation (List separately in addition to code for primary procedure[s]).
    Related CPT CodesCPT
    31615Tracheobronchoscopy through established tracheostomy incision.
    31622Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure).
    31623with brushing or protected brushings.
    31624with bronchial alveolar lavage.
    31625with bronchial or endobronchial biopsy(s), single or multiple sites.
    31626with placement of fiducial markers, single or multiple.
    31628with transbronchial lung biopsy(s), single lobe.
    31629with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i).
    31630with tracheal/bronchial dilation or closed reduction of fracture.
    31631with placement of tracheal stent(s) (includes tracheal/bronchial dilation as required).
    1–10 of 16
    1/2
    Covered HCPCS Codes (if selection criteria met)HCPCSCovered
    C7509Bronchoscopy, rigid or flexible, diagnostic with cell washing(s) when performed, with computer-assisted image-guided navigation, including fluoroscopic guidance when performed.
    C7510Bronchoscopy, rigid or flexible, with bronchial alveolar lavage(s), with computer-assisted image-guided navigation, including fluoroscopic guidance when performed.
    C7511Bronchoscopy, rigid or flexible, with single or multiple bronchial or endobronchial biopsy(ies), single or multiple sites, with computer-assisted image-guided navigation, including fluoroscopic guidance when performed.
    ICD-10 Codes (examples covered if selection criteria met)ICD-10
    R91.1Solitary pulmonary nodule [peripheral pulmonary nodule].
    R91.8Other nonspecific abnormal finding of lung field [peripheral pulmonary nodules].
    Not covered / Experimental proceduresmixedNot Covered
    no specific codeElectromagnetic navigation bronchoscopy-guided microwave ablation; Cone-beam CT augmented electromagnetic navigation (EN)-guided bronchoscopy; Trans-bronchial lung cryo-biopsy for improvement of diagnostic yield of digital tomosynthesis-assisted EN-guided bronchoscopic biopsy — listed as not covered/experimental.
    Codes referencedmixed
    No specific CPT/HCPCS/ICD-10 codes listed in this document segment
    inv-16: lesion size — studies report varied yields for lesions <20–30 mm (lower yield <20 mm)
    General findingStudies report varied diagnostic yields for lesions under approximately 20–30 mm, with lower yields for the smallest lesions.
    Becker et al. (2005)Reported diagnostic yield of 69% in 29 patients with isolated peripheral lung lesions (lesion sizes not specified here).
    Makris et al. (2007)Overall diagnostic yield 62.5% (mean lesion diameter 23.5 mm); yield increased to 77.2% when CT-to-body divergence ≤4 mm.
    Eberhardt et al. (2007b)In nodules <30 mm (mean 23.3 mm, range 14–29 mm) diagnostic yield was 72.2%; one small pneumothorax occurred (1.92%).
    inv-17: Lesion size references — Many studies report outcomes for lesions <20 mm or <2 cm; diagnostic yield trends lower for lesions <2 cm
    Size thresholds reportedMultiple sources report outcomes specifically for lesions <20 mm or <2 cm and note diagnostic yield trends lower for lesions <2 cm.
    Conventional bronchoscopy yieldsConventional flexible bronchoscopy diagnostic yield: ~69% for lesions >20 mm and ~33% for lesions <20 mm (Mazzone et al, Rivera et al).
    ACCP / literature summaryACCP literature review identified studies of nodules <2 cm with diagnostic yields ranging 44–75% (median 68.5%).

    Provider Actions, Prior Authorization, and Documentation

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required when billing EN-guided bronchoscopy codes. Submit prior authorization with clinical documentation that selection criteria for medical necessity are met (per policy: peripheral pulmonary nodule requiring pathologic diagnosis and not accessible by standard bronchoscopy or transthoracic biopsy).

    • Affected codes: CPT 31627 and related bronchoscopy procedure codes; HCPCS C7509–C7511. ICD-10 examples: R91.1, R91.8.
    Prior Authorization

    Prior Authorization Expectation

    Prior authorization may be appropriate when ENB is planned for biopsy, fiducial placement, dye marking, or lymph node sampling. Provide a clear clinical rationale for the planned use and target lesion(s).

    • Document intended procedure: diagnostic biopsy, fiducial placement (CPT 31626), or lymph node sampling (e.g., TBNA).
    • If ENB is used adjunctively (e.g., for dye marking), explain why alternatives are unsuitable.
    Prior Authorization

    Prior Authorization for Combined/Novel ENB Procedures

    If ENB is proposed to guide adjunctive or novel interventions (for example, microwave ablation, cone-beam CT augmentation, or other combined procedures), submit prior authorization and document the rationale and intended combined procedure.

    • Examples: ENB-guided microwave ablation (investigational per policy), ENB combined with VATS or CBCT confirmation. Note: some combined procedures are considered experimental/investigational; see policy.
    • Provide evidence supporting use and anticipated benefit over standard approaches.
    Denial Risk

    Indication Mismatch Risk

    Denials may occur if the indication does not match the policy (e.g., not a peripheral pulmonary nodule requiring pathologic diagnosis) or if the lesion is accessible by standard bronchoscopy or by transthoracic biopsy approaches.

    • Confirm indication: solitary/peripheral pulmonary nodule (ICD-10 R91.1 or R91.8) requiring tissue diagnosis.
    • If lesion is reachable by standard bronchoscopy or TTNA with acceptable risk, document why ENB is preferred.
    Denial Risk

    Comparative Evidence and Denial Risk

    Comparative evidence indicates ENB-guided biopsy has lower diagnostic yield than CT-guided transthoracic needle aspiration (TTNA) but lower pneumothorax rates. Absent justification of benefit or patient-specific rationale, requests may be denied.

    • Reference assessments (e.g., NICE) showing lower diagnostic yield vs TTNA but lower complication rates.
    • If choosing ENB over TTNA, document patient-specific risks for TTNA and why ENB is preferred.
    Denial Risk

    CBCT-Related Resource and Radiation Concerns

    When cone-beam CT (CBCT) is used with ENB, document justification given CBCT-related resource needs and additional radiation exposure. Failure to justify access to CBCT or additional radiation may increase denial risk.

    • Document expected benefit of CBCT confirmation (improved localization/real-time confirmation) and number of anticipated CBCT spins.
    • If CBCT resources are limited, note plans for resource sharing or ancillary staff training and patient discussion of radiation risk.
    Documentation Required

    Clinical and Coding Documentation

    Clinical and coding documentation must support the diagnosis and medical necessity. Include codes and diagnosis rationale (e.g., ICD-10 R91.1 or R91.8) and state that the peripheral pulmonary nodule is not accessible by standard bronchoscopy.

    • Include primary ICD-10 diagnosis (e.g., R91.1), planned CPT/HCPCS codes, and clinical reason ENB is required.
    • Ensure coding aligns with the actual procedures performed and any add-on/navigation codes are listed appropriately.
    Documentation Required

    Lesion Characteristics and Tissue Needs

    Documentation should include lesion size, location, and the need for adequate tissue for histologic and molecular characterization. Provide the rationale for choosing ENB to obtain sufficient tissue for diagnosis and molecular testing.

    • Lesion metrics: maximum diameter (mm/cm), lobe and segment location, presence/absence of bronchus sign.
    • State diagnostic goals: histology, immunohistochemistry, and molecular tests required (e.g., for NSCLC).
    Documentation Required

    Required Procedural Documentation

    Procedural documentation must record lesion characteristics, navigational modalities used, biopsy tools and the sequence of sampling, and any adjunct imaging or confirmation techniques.

    • Record navigational modalities: ENB, RP-EBUS, CBCT, fluoroscopy.
    • List biopsy tools and sequence (example sequence from pilot studies: TBNA, then forceps, then TBLC) and number of passes per tool.
    • Document whether fiducials were placed, dye marking performed, or adjunctive ablation attempted.
    Documentation Required

    Consideration of Alternative Diagnostic Modalities

    Document that alternative diagnostic modalities (e.g., TTNA, rEBUS, conventional bronchoscopy) were considered and why they were not appropriate or were less desirable for this patient.

    • If TTNA was considered, document specific patient risk factors that make TTNA high risk.
    • If rEBUS or conventional bronchoscopy considered, document lesion features that limit their utility (e.g., peripheral location, lack of bronchus sign).
    Note

    Suggested Sequential Biopsy Approach

    A sequential biopsy approach may be considered and should be documented when used. Pilot studies have used TBNA first, then forceps biopsy, and finally trans-bronchial lung cryo-biopsy (TBLC) to maximize diagnostic yield.

    • If sequential sampling is planned, list the intended order of modalities and rationale.
    • Document results of each sampling method and any change in approach during the procedure.

    Background and Clinical Context

    Conventional flexible bronchoscopy is limited by bronchoscope diameter and the branching anatomy of the airways, which constrains access to small peripheral lesions. Diagnostic yield with standard bronchoscopy decreases notably for small lesions (several studies and guideline statements highlight lower yields for lesions ~20 mm). ENB was developed as a CT-based, image-guided navigation technique to guide a locatable probe and instruments through the bronchoscope to peripheral lung lesions, potentially improving access and enabling procedures such as fiducial placement and targeted biopsy.

    Definitions and Study Descriptions

    inv-31: Electromagnetic navigational bronchoscopy (ENB) — CT-image–based, computer-assisted navigation system guiding sensor-equipped catheter
    DefinitionA CT-image–based, computer-assisted navigation system that guides a sensor-equipped catheter through the bronchoscope to peripheral lung lesions using electromagnetic tracking and virtual 3-D reconstructions.
    FunctionSystem reconstructs CT scans into 3-D images, registers airway points via a microsensor probe, and maps a route for the bronchoscope and tools to reach peripheral lesions.
    Use casesUsed for biopsy of peripheral pulmonary nodules and for placement of fiducial markers or dye marking when needed for treatment planning.
    inv-32: Fiducial markers — Radiologic landmarks implanted to aid precise localization for radiotherapy
    DefinitionRadiologic landmarks (e.g., gold seeds or stainless steel screws) implanted in and/or around a tumor to act as a radiologic landmark for more precise localization during radiotherapy or image-guided procedures.
    Placement methodsFiducial markers may be placed using CT, endoscopic (including ENB-guided), or surgical guidance.
    PurposeAid precise localization of soft-tissue tumors for radiation targeting and treatment planning.
    inv-33: Electromagnetic navigation bronchoscopy (ENB) definition variant — image-guided bronchoscopic technique combining CT virtual bronchoscopy with electromagnetic field and locatable probe
    Technique descriptionAn image-guided bronchoscopic technique combining CT-based virtual bronchoscopy with an electromagnetic field and a locatable probe to navigate instruments to peripheral pulmonary lesions.
    Navigation toolsIncorporates virtual bronchoscopy imaging plus an electromagnetic field to guide biopsy equipment (forceps, brush, guide sheath) to the target lesion.
    Adjunct useCan be used alone or together with radial probe EBUS to improve lesion localization and sampling.
    inv-34: NAVIGATE study — Large prospective, multi-center observational study evaluating the superDimension ENB system
    Study typeNAVIGATE is a large prospective, multi-center observational cohort study evaluating the superDimension ENB system across academic and community sites.
    Cohort size and endpointsIn the larger cohort (1,215 enrolled; 1,157 underwent ENB-guided biopsy) median lesion size was 20 mm; navigation completed and tissue obtained in ~94% of procedures.
    Key reported outcome12-month diagnostic yield reported as 73% with ENB-related grade ≥2 pneumothorax rate of 2.9% (Folch et al. cohort).
    inv-35: ENB — navigation technique using virtual bronchoscopy imaging combined with electromagnetic field to guide instruments
    Core conceptENB uses virtual bronchoscopy imaging combined with an electromagnetic field to guide bronchoscopic instruments to target peripheral pulmonary lesions.
    EquipmentGuidance system directs a sensor-equipped catheter or locatable probe through the bronchoscope working channel along a CT-planned path.
    ApplicationsGuides biopsy tools, fiducial placement, and can be combined with other navigational aids to improve access to peripheral lesions.
    inv-36: CBCT-augmented ENB — ENB used with cone-beam CT for secondary confirmation of biopsy tool position
    DefinitionENB combined with cone-beam CT (CBCT) provides secondary, intra-procedural confirmation of biopsy tool position within the target lesion to potentially improve diagnostic yield.
    Study evidencePodder et al. (2022) reported CBCT-augmented ENB diagnostic yield of 76% (13/17 nodules) in a single-center observational series with no immediate complications.
    Rationale and limitsCBCT provides real-time localization information but may increase radiation exposure and requires hybrid OR resources and expertise.
    inv-37: TBLC (Trans-bronchial lung cryobiopsy) — Cryo-probe biopsy technique via bronchoscopy evaluated as adjunct to ENB-guided biopsy
    TechniqueTrans-bronchial lung cryobiopsy (TBLC) uses a 1.1-mm cryo-probe via bronchoscopy to retrieve larger tissue samples and can be performed sequentially after other bronchoscopic biopsies.
    Pilot study resultsBenn et al. (2022) pilot: sequential TBNA, forceps, then TBLC (n=42 patients, 45 nodules) produced a final diagnostic yield of 93% (42/45); TBLC contributed additional unique diagnoses and no major bleeding or pneumothorax reported.
    Role with ENBTBLC was evaluated as an adjunct to ENB-guided biopsy (with digital tomosynthesis) to improve diagnostic yield for small, peripheral nodules.