CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Bronchial Valves

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Bronchial Valves

Policy CodePolicy N/A

Change TypeClarified - not covered

Effective DateJan 1, 2016

Next Review Date

Key ActionBronchial valve procedures for prolonged air leaks or COPD/emphysema are considered not covered/not medically necessary; providers should refer to the member's Benefit Booklet/Evidence of Coverage or Subscriber Agreement and obtain any required authorization per contract terms.

SourceLink

POLICY UPDATE CHANGES

Policy states bronchial valves are not covered for prolonged air leaks or for COPD/emphysema due to insufficient evidence.

2Primary non-covered indications

4Procedure CPT codes listed

Coverage Summary

Defines Blue Cross Blue Shield Rhode Island coverage position for bronchial (endobronchial) valves used to treat prolonged bronchopleural air leaks, COPD, or emphysema, and lists associated CPT procedure codes. Applies to BlueCHiP for Medicare and Commercial products; notes benefits may vary by contract. Background: evidence to date shows uncertain clinical benefit and raises safety concerns, leading to an overall insufficient evidence determination.

Medical-Necessity / Coverage Determination

Coverage Determination

Use of bronchial valves is considered not covered / not medically necessary when used for the following indications:

ANY of the following

Treatment of prolonged air leaks (bronchopleural air leaks).
Treatment of chronic obstructive pulmonary disease (COPD) or emphysema (including as alternative to lung volume reduction surgery).

Not Covered / Experimental

Policy conclusion: Bronchial valves are not covered / not medically necessary for treatment of prolonged bronchopleural air leaks and for treatment of COPD/emphysema (including as an alternative to lung volume reduction surgery). The policy clarifies that these indications are considered not covered due to insufficient evidence to determine effects on health outcomes.

Evidence note: Key randomized trial cited is Sciurba FC et al., N Engl J Med. 2010. Overall evidence shows uncertain clinical benefit and trials reported numerous adverse events, raising safety concerns, resulting in an insufficient evidence determination.

Coding

Commercial Procedure Codes (listed in policy text)CPTNot Covered

31647	Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve(s), initial lobe
31648	Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal of bronchial valve(s), initial lobe
31649	Bronchoscopy, rigid or flexible; including fluoroscopic guidance, when performed; with removal of bronchial valve(s), each additional lobe (List separately in addition to code for primary procedure)
31651	Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, assessment of air leak, airway and insertion of bronchial valve(s), each additional lobe (List separately in addition to code for primary procedure[s]) sizing;

Provider Actions

Documentation Required

Do not bill as covered without justification

Bronchial valve procedures for prolonged air leaks or COPD/emphysema are considered not covered/not medically necessary; providers should refer to the member's Benefit Booklet/Evidence of Coverage or Subscriber Agreement for applicable coverage and obtain any required authorization per contract terms.

31647
31648
31649
31651
Refer to member Benefit Booklet/Evidence of Coverage or Subscriber Agreement; obtain any required authorization per contract terms.

Background and Definitions

Bronchial valves are one-way devices placed bronchoscopically into airways to control airflow. They have been investigated for management of prolonged bronchopleural air leaks and as a nonsurgical alternative to lung volume reduction in patients with emphysema. Evidence to date is insufficient to determine clinical benefit, and trials have raised safety concerns.

Definition — Bronchial valve: A synthetic one-way valve deployed bronchoscopically into airways to control airflow, permit exhalation and limit inhalation to diseased lung areas.

Revision History

2016-01-01clarified

Policy states bronchial valves are not covered for prolonged air leaks or for COPD/emphysema due to insufficient evidence.

2018-08-07clarifiedLatest

Policy states bronchial valves are not covered for prolonged air leaks or for COPD/emphysema due to insufficient evidence.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Bronchial Valves

Policy CodePolicy N/A

Change TypeClarified - not covered

Effective DateJan 1, 2016

Next Review Date

SourceLink

On This Page

OpenPayer

Medical Coverage Policy Bronchial Valves

Coverage Summary

Medical-Necessity / Coverage Determination

Not Covered / Experimental

Coding

Provider Actions

Background and Definitions

Evidence Cited

Revision History