CurrentBlue Cross Blue Shield - MassachusettsPolicy 715

Endobronchial ultrasound (EBUS) with transbronchial needle aspiration (TBNA)

Clinical coverage guidance for use of endobronchial ultrasound with transbronchial needle aspiration for diagnosis of peripheral pulmonary lesions and mediastinal staging in suspected or confirmed lung cancer for Blue Cross Blue Shield - Massachusetts members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyEndobronchial ultrasound (EBUS) with transbronchial needle aspiration (TBNA)

Policy CodePolicy 715

Change TypeNo material changes

Effective DateApr 1, 2015

Next Review DateNov 1, 2025

Key ActionObtain precertification/preauthorization for inpatient procedures; outpatient prior authorization is not required for most products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Distinct covered indications

3EBUS CPT codes listed

inpatientPrecertification requirement

not requiredOutpatient prior auth

sufficient

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Coverage Criteria for EBUS-TBNA

Diagnosis of peripheral pulmonary lesions

Covered when ALL of the following are met

Peripheral pulmonary lesion diagnosis: Tissue biopsy of the peripheral pulmonary lesion is required for diagnosis

Peripheral pulmonary lesion diagnosis: The peripheral pulmonary lesion is not accessible using standard bronchoscopic techniques

Mediastinal staging

Covered when ALL of the following are met

Mediastinal staging: The individual is suitable and willing to undergo specific treatment for lung cancer, with either curative or palliative intent

Mediastinal staging: Tissue biopsy of abnormal mediastinal lymph nodes seen on imaging is required for staging and specific treatment planning

Mediastinal staging: Abnormal lymph nodes seen on imaging are accessible by EBUS-TBNA biopsy

Covered Indications

Covered when supported by evidence summary

Diagnostic use for peripheral pulmonary lesions: EBUS-TBNA has diagnostic performance characteristics similar to flexible bronchoscopy with transthoracic needle aspiration for solitary peripheral pulmonary lesions and improves net health outcome due to diagnostic performance and safety profile

based on systematic reviews, meta-analyses, and small randomized trials; see cited evidence

Staging use for mediastinal lymph nodes: EBUS-TBNA exhibits test performance characteristics similar to other needle-based mediastinal staging methods in patients with lung cancer and mediastinal lymph nodes on imaging, and results in improved net health outcome

based on systematic reviews and meta-analyses; see cited evidence

Endobronchial ultrasound (EBUS) is investigational when the policy's coverage criteria are not met. Specifically, EBUS-TBNA is considered investigational for diagnosis or mediastinal staging of lung cancer if the listed medical-necessity conditions (e.g., requirement for tissue biopsy, accessibility of the lesion or lymph node, and suitability for treatment) are not satisfied. The policy also states that EBUS is investigational for all other indications beyond those defined as medically necessary.

The evidence summary provided with the policy does not enumerate additional explicit exclusions to coverage for EBUS-TBNA; instead, coverage is framed by the specific medical-necessity criteria and the summarized evidence supporting diagnostic and staging uses.

When the criteria for medical necessity are not met, the policy treats EBUS as investigational rather than listing the procedure as explicitly not medically necessary; therefore, procedures that fall outside the defined indications would be declined on the basis that they are investigational under this policy.

The document does not present a separate list of services explicitly labeled not medically necessary. Instead, the policy uses the investigational designation for services that do not meet the stated medical-necessity criteria, and the evidence summary focuses on circumstances in which EBUS-TBNA is supported for diagnosis or staging.

Relevant Procedure and Diagnosis Codes

Covered CPT Codes (informational)CPT

31652	Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (ebus) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures.
31653	Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (ebus) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node stations or structures.
31654	Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transendoscopic endobronchial ultrasound (ebus) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s) (list separately in addition to code for primary procedure(s)).

ICD-10 Diagnosis Codes (informational)ICD-10

C34.00	Malignant neoplasm of unspecified main bronchus.
C34.01	Malignant neoplasm of right main bronchus.
C34.02	Malignant neoplasm of left main bronchus.
C34.10	Malignant neoplasm of upper lobe, unspecified bronchus or lung.
C34.11	Malignant neoplasm of upper lobe, right bronchus or lung.
C34.12	Malignant neoplasm of upper lobe, left bronchus or lung.
C34.2	Malignant neoplasm of middle lobe, bronchus or lung.
C34.30	Malignant neoplasm of lower lobe, unspecified bronchus or lung.
C34.31	Malignant neoplasm of lower lobe, right bronchus or lung.
C34.32	Malignant neoplasm of lower lobe, left bronchus or lung.

1–10 of 40

1/4

Solitary pulmonary nodule size mention

Typical size definitionSolitary pulmonary nodules are most often defined as asymptomatic nodules less than 8 mm

Clinical implicationSmaller/ peripheral nodules (<8 mm) are more difficult to evaluate and may have low diagnostic sensitivity with standard techniques

Imaging detectionSolitary pulmonary lesions are typically identified on chest radiographs or chest CT scans, often incidentally

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Precertification (prior authorization) is required when the procedure is performed inpatient. Outpatient procedures for the products listed do not require prior authorization.

Inpatient: precertification/preauthorization IS REQUIRED for all products if performed inpatient.
Outpatient: Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, Medicare HMO Blue SM, and Medicare PPO Blue SM — prior authorization is not required for outpatient procedures.

Note

Authorization — Evidence Summary Only

The policy's evidence summary supports the medical necessity statements for EBUS-TBNA in diagnosis of peripheral pulmonary lesions and mediastinal staging when criteria are met, but this section does not establish additional authorization conditions beyond the prior authorization requirement for inpatient services.

Evidence supports diagnostic performance and safety of EBUS-TBNA for peripheral lesions and mediastinal staging when policy criteria are met.

Clinical Background and Rationale

Lung cancer management and the diagnostic approach depend on how the disease presents, where lesions are located, and the stage at diagnosis. Early and accurate diagnosis guides definitive treatment decisions. Peripheral pulmonary nodules are often incidentally detected on chest radiography or CT and can be more challenging to access for tissue sampling than central lesions. Diagnostic options include sputum cytology, standard flexible bronchoscopy, transthoracic CT-guided needle aspiration, surgical biopsy, and bronchoscopy augmented by endobronchial ultrasound probes. The policy notes that EBUS (radial and convex probes) can improve localization and sampling of peripheral lesions and mediastinal lymph nodes, and the evidence summary indicates that EBUS-TBNA has diagnostic performance similar to alternative approaches and a potentially improved safety profile, supporting its use for both peripheral lesion diagnosis and mediastinal staging when criteria are met.

Key Definitions

EBUS-TBNA

DefinitionEBUS-TBNA: Endobronchial ultrasound guidance with transbronchial needle aspiration — use of radial or convex ultrasound probes during bronchoscopy to localize and obtain tissue from peripheral pulmonary lesions or mediastinal lymph nodes

Radial probe useRadial probe EBUS (20–30 MHz rotating transducer) provides high-resolution 360° images to locate peripheral lesions; does not allow real-time biopsy guidance

Convex probe useConvex (curved linear) probe EBUS (5–12 MHz) provides real-time sector views and enables real-time needle aspiration for mediastinal node staging

PurposeFacilitates navigation to distal lung regions and biopsy of peripheral nodules and mediastinal lymph nodes as part of diagnosis and staging