Endobronchial Valves
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This policy defines medical necessity criteria, coverage limitations, and coding guidance for placement of endobronchial (bronchial) valves for treatment of severe emphysema and for prolonged postoperative air leaks, for Blue Cross Blue Shield of North Carolina commercial members.
No material clinical or coverage changes in this revision.
Coverage Criteria
Endobronchial valve placement for severe emphysema (Initial therapy)
Covered when ALL of the following are met
Provider attestation required
Fissure completeness assessed by quantitative CT; Chartis used when fissure <90%
Endobronchial valve placement for prolonged postoperative air leaks
Covered when ALL of the following are met
An air leak present on postoperative day 7 is considered prolonged unless present only during forced exhalation or cough; consider treatment on day 5 if continuous, present during normal inhalation, or present on normal expiration with subcutaneous emphysema or respiratory compromise.
Spiration IBV is approved under HDE for control of prolonged or significant air leaks
Use of endobronchial valves for the treatment of emphysema is investigational (not covered) for all situations not explicitly listed as covered. This includes, but is not limited to, patients who do not meet the coverage criteria in the "When Endobronchial Valves are covered" section, those with prior ipsilateral lung volume reduction surgery or lung/lobar transplant, patients for whom bronchoscopy is contraindicated, and patients with active pulmonary infection, known relevant material allergies, or large bullae (>30% of either lung).
Endobronchial valves are considered investigational and therefore not covered for emphysema in patients who do not meet the specified coverage criteria and in the other excluded situations listed in the policy. Specific excluded situations include prior ipsilateral lung volume reduction surgery or lung/lobar transplant, contraindicated bronchoscopy, active pulmonary infection, known allergies to Nitinol or silicone (unless being managed by an allergist), and large bullae greater than 30% of either lung.
Coding & Clinical Thresholds
| 31647 | Bronchoscopy, rigid or flexible, with bronchoscopic placement of intrabronchial valves (listed in policy as applicable service codes) |
| 31648 | Bronchoscopy with removal or replacement of intrabronchial valve(s) (listed in policy as applicable service codes) |
| 31649 | Bronchoscopy with therapeutic procedures related to intrabronchial valve placement (listed in policy as applicable service codes) |
| 31651 | Bronchoscopy with placement of multiple intrabronchial valves (listed in policy as applicable service codes) |
Provider Actions & Requirements
Prior authorization required; use listed CPT codes
Prior authorization is required per payer processes and the policy lists applicable service CPT codes; medical necessity must meet the criteria in the 'When Endobronchial Valves are covered' section.
Confirm PA requirements with member benefits
The policy text does not specify benefit-level prior authorization rules; whether a PA is required for a given member is determined by the member's benefits and eligibility.
- Check the group contract and subscriber certificate for benefit-specific PA requirements.
Conservative management and pulmonary rehabilitation required
Patients must have persistent dyspneic symptoms despite maximal medical management and must have attended or enrolled in a pulmonary rehabilitation program prior to valve placement.
- Provider attestation that the patient has attended or enrolled in pulmonary rehabilitation is required.
- Other required thresholds (FEV1, 6MWD, age, smoking abstinence, steroid stability, collateral ventilation assessment) must also be met.
Administrative update — no change to coverage criteria
Administrative/provider note: multiple policy updates list 'No change to policy statement'—these are administrative updates and do not alter coverage criteria.
- Administrative updates (2023–2026) updated references and guidelines but did not change the policy statement.
Medical records may be requested; letters alone may be insufficient
BCBSNC may request medical records to determine medical necessity; letters of support/explanation are not sufficient unless they include all specific clinical information required for the determination.
- Provide complete medical records when requested to support the medical necessity review.
Attestation of pulmonary rehabilitation and smoking abstinence
Provider must attest that the patient has attended or is enrolled in a pulmonary rehabilitation program and must document abstinence from smoking for 4 consecutive months prior to initial evaluation and throughout the evaluation.
- Document smoking abstinence of any kind for 4 consecutive months prior to initial evaluation.
- Include provider attestation of pulmonary rehabilitation attendance or enrollment in submitted documentation.
Policy is informational — verify member benefits and eligibility
This policy is informational and is not an authorization, certification, explanation of benefits, or a contract; benefits and eligibility are determined by the group contract and subscriber certificate in effect at the time of service.
- Verify member benefits and eligibility before submitting authorization or performing services.
Avoid procedures for excluded/ investigational indications — risk of denial
Procedures performed for indications outside the listed covered situations (for example, emphysema patients who do not meet the when-covered criteria, prior ipsilateral lung volume reduction surgery or lung/lobar transplant, contraindicated bronchoscopy, active pulmonary infection, known allergies to Nitinol or silicone, or large bullae >30%) may be considered investigational and denied.
- Do not submit claims or requests for patients who meet any of the listed exclusion criteria; these situations are considered investigational.
Administrative update note — updates do not change coverage
Administrative updates noted in multiple entries indicate no change to the policy statement; these administrative updates do not alter coverage decisions.
- Updates in 2023–2026 revised descriptions, guidelines, references, and reviews but explicitly state no change to the policy statement.
Background
Endobronchial valves are bronchoscopically placed devices intended to reduce airflow to diseased lung regions, promoting volume reduction or atelectasis in targeted areas for treatment of severe emphysema and to help control prolonged postoperative bronchopleural air leaks. Patient selection for emphysema therapy typically requires assessment for absence of significant collateral ventilation (evaluated by the Chartis system or by quantitative CT fissure analysis), demonstration of persistent symptoms despite maximal medical management with enrollment or participation in pulmonary rehabilitation, and meeting physiologic thresholds such as FEV1 15%–45% predicted and 6-minute walk distance ≥100 m and <500 m.
Definitions
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