CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Bronchial Valves

Defines Blue Cross Blue Shield Rhode Island coverage position for bronchial valves used for prolonged bronchopleural air leaks and for treatment of COPD/emphysema, including coding guidance and benefit applicability for Medicare (BlueCHiP) and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Bronchial Valves

Policy CodePolicy N/A

Change Typeclarified

Effective DateJan 1, 2016

Next Review Date

Key ActionRefer to the applicable Benefit Booklet, Evidence of Coverage or Subscriber Agreement for group/contract-specific benefits to determine whether bronchial valves are covered under the member's plan.

SourceLink

POLICY UPDATE CHANGES

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

2Indications classified as not covered/not medically necessary

4CPT codes listed as not covered/not medically necessary

Coverage Summary

This policy states that bronchial valves are not covered for BlueCHiP for Medicare and are considered not medically necessary for Commercial Products for the indications of prolonged bronchopleural air leaks and for treatment of COPD/emphysema due to insufficient evidence to determine effects on health outcomes. The same noncoverage/not medically necessary stance applies to both Medicare (BlueCHiP) and Commercial products.

Applicability: BlueCHiP for Medicare—use of bronchial valves for prolonged air leaks or for COPD/emphysema is considered not covered. Commercial Products—use of bronchial valves for prolonged air leaks or for COPD/emphysema is considered not medically necessary. Benefits may vary by group or contract; providers should consult the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for member-specific benefits.

Quick Facts

Effective Date01/01/2016

Last Review06/18/2020

Policy StatusCURRENT

Scope SummaryDefines Blue Cross Blue Shield Rhode Island coverage position for bronchial valves used for prolonged bronchopleural air leaks and for treatment of COPD/emphysema, including coding guidance and applicability to BlueCHiP for Medicare and Commercial Products.

Coverage StanceNot covered for BlueCHiP for Medicare; Not medically necessary for Commercial Products (insufficient evidence).

Coverage Determination / Medical Necessity

Coverage Determination

Coverage of bronchial valves is determined as follows:

ALL of the following

Use of bronchial valves for the treatment of prolonged air leaks is considered not covered due to insufficient evidence to determine the effects of the technology on health outcomes (BlueCHiP for Medicare).
Use of bronchial valves for the treatment of chronic obstructive pulmonary disease (COPD) or emphysema is considered not covered due to insufficient evidence to determine the effects of the technology on health outcomes (BlueCHiP for Medicare).
For Commercial Products: Use of bronchial valves for the treatment of prolonged air leaks or for treatment of COPD or emphysema is considered not medically necessary due to insufficient evidence to determine the effects of the technology on health outcomes.

Coding Guidance

Primary procedure codes (listed as not covered)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

Additional procedure codes (listed as not covered)CPTNot Covered

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;
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)
31648	Bronchoscopy, rigid Or flexible, including fluoroscopic guidance, when performed; with removal of bronchial valve(s), initial lobe

Claims for bronchial valve insertion or removal for prolonged air leaks or COPD/emphysema may be denied or not covered per policy due to insufficient evidence; providers should refer to applicable benefit booklets or subscriber agreements and follow participation agreements and informed written consent before billing members.

Provider Actions & Billing Impact

Documentation Required

Benefit verification

Refer to the applicable Benefit Booklet, Evidence of Coverage or Subscriber Agreement for group/contract-specific benefits to determine whether bronchial valves are covered under the member's plan.

Check the member's Benefit Booklet / Evidence of Coverage for contract-specific coverage.

Denial Risk

Claims may be denied as not medically necessary

Claims for bronchial valve insertion or removal for prolonged air leaks or COPD/emphysema may be denied or determined not covered/not medically necessary per policy due to insufficient evidence; providers should not bill members except as allowed by participation agreements and informed written consent.

Affected CPT codes: 31647, 31648, 31649, 31651
Do not bill members for services determined not medically necessary or not covered unless allowed by participation agreements and with informed written consent.

Background & Evidence

Bronchial valves are endobronchial one-way valves placed bronchoscopically to reduce airflow to diseased lung regions—used to treat persistent air leaks or as a nonsurgical alternative to lung volume reduction for emphysema. Evidence to date shows uncertain clinical benefit, and numerous adverse events in trials raise safety concerns; overall the evidence is insufficient to determine the effects of the technology on health outcomes.

Multiple trials and case series have been cited with mixed outcomes and safety concerns (examples include Travaline 2009; Sciurba 2010; BeLieVeR-HIFi 2015). Although some outcomes favored bronchial valve treatment in certain studies, the magnitude of benefit was generally of uncertain clinical significance and adverse events raise concerns, leading to an overall conclusion of insufficient evidence to support coverage.

Bronchial valve: A synthetic one-way valve placed bronchoscopically in airways to control airflow and potentially treat air leaks or reduce hyperinflation.

Revision History

2016-01-01effective date

Policy effective date

2020-06-18last reviewLatest

Policy last updated

policy clarificationLatest

Applies to both BlueCHiP for Medicare and Commercial Products. Policy states bronchial valves are not covered/not medically necessary for prolonged air leaks and for COPD/emphysema due to insufficient evidence.