CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Electromagnetic Navigation Bronchoscopy (ENB) — Medical Coverage Policy

Policy governing the medical necessity and coverage of electromagnetic navigation bronchoscopy for diagnosis of peripheral pulmonary lesions and placement of fiducial markers; applies to BlueCHiP for Medicare and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyElectromagnetic Navigation Bronchoscopy (ENB) — Medical Coverage Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionVerify member benefits and coverage details in the Benefit Booklet/Evidence of Coverage before scheduling ENB as benefits may vary by contract.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

31626,31627CPT codes listed as covered

Mediastinal not coveredCoverage restriction (Medicare)

Not medically necessary for mediastinalCoverage stance (Commercial)

2020-01-01Policy effective date

9References in extract

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

Medically Necessary Uses

Covered when ALL of the following are met

ENB medical necessity: Flexible bronchoscopy alone, or with endobronchial ultrasound, is considered inadequate to accomplish the diagnostic or interventional objective AND ENB is used to either establish a diagnosis of suspicious peripheral pulmonary lesion(s) OR place fiducial markers within tumor(s) prior to lung treatment.

Applies to BlueCHiP for Medicare and Commercial Products

Use of electromagnetic navigation bronchoscopy (ENB) in conjunction with flexible bronchoscopy for the diagnosis of mediastinal lymph nodes is not covered for BlueCHiP for Medicare and is considered not medically necessary for Commercial products. The policy states that ENB for this indication and for any other uses not listed as covered is not supported because the evidence is insufficient to determine effects on health outcomes.

No additional explicit clinical exclusions are stated in the provided extract. Benefits and eligibility are determined by the member’s subscriber agreement or employer agreement, which supersede this medical policy.

As noted above, ENB used with flexible bronchoscopy for mediastinal lymph node diagnosis is considered not covered / not medically necessary and will be denied under the policy for the respective product lines.

Services determined to be not medically necessary (or medically necessary but non-covered benefits) may not be paid. Providers may not bill members for such services unless the member has been informed and has agreed in writing in advance to accept financial responsibility.

Coding

Covered CPT CodesCPTCovered

31626	Bronchoscopy, rigid Or flexible, including fluoroscopic guidance when performed; with placement of fiducial markers, single Or multiple
31627	Bronchoscopy, flexible, including fluoroscopic guidance when performed; with computer assisted, image-guided navigation (List separately in addition to code for primary procedure)

Unlisted / Reporting GuidanceCPT

UNLISTED

Unlisted procedure code for electromagnetic navigation bronchoscopy when used for the diagnosis of mediastinal lymph nodes (no specific CPT exists)

Provider Actions & Billing

Prior Authorization

Prior authorization: Not applicable. Verify member benefits and coverage prior to performing services; benefits may vary by contract and subscriber agreement.

Verify benefits with member's subscriber agreement/benefit booklet/Evidence of Coverage
Contact provider call center for member-specific benefits

Denial Risk

Mediastinal Lymph Node Diagnosis Exclusion

Electromagnetic navigation bronchoscopy (ENB) is not covered / not medically necessary for use with flexible bronchoscopy for the diagnosis of mediastinal lymph nodes (BlueCHiP for Medicare and Commercial Products). ENB for this indication will be denied.

Do not submit ENB for mediastinal lymph node diagnosis as a covered service
Report an unlisted procedure code if attempting to report ENB for mediastinal nodes (no specific CPT exists)

Background

Electromagnetic navigation bronchoscopy augments standard bronchoscopy by providing a 3-dimensional roadmap of the lungs and real‑time information about the position of a steerable probe, allowing navigation to distal lesions for biopsy or placement of fiducial markers to aid radiotherapy planning.

Definitions

Electromagnetic Navigation Bronchoscopy (ENB) — definition and brief description

DefinitionA bronchoscopy technique that provides a 3-dimensional roadmap of the lungs and real-time information about the position of a steerable probe to reach distal lesions and allow biopsy or fiducial marker placement.

PurposeIntended to enhance standard bronchoscopy by enabling navigation to distal regions of the lungs so suspicious lesions can undergo biopsy and to facilitate placement of fiducial markers.

MechanismUses a navigation catheter through which endoscopic tools (e.g., transbronchial forceps) or fiducial markers can be delivered to the target lesion under real-time guidance.

Peripheral pulmonary nodule — definition and context about peripheral lesions

DefinitionA pulmonary nodule typically identified on chest radiograph or CT; solitary pulmonary nodules are often asymptomatic and in some contexts described as <6 mm.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyElectromagnetic Navigation Bronchoscopy (ENB) — Medical Coverage Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionVerify member benefits and coverage details in the Benefit Booklet/Evidence of Coverage before scheduling ENB as benefits may vary by contract.

SourceLink

On This Page

Denial Risk

Billing and Denial Risk Notice

Services determined to be not medically necessary or otherwise non‑covered may result in provider non‑payment and potential member balance billing unless the member has agreed in writing in advance to self‑pay. This policy is informational and not a guarantee of payment; benefits and eligibility are determined by the member's subscriber agreement/member certificate and/or employer agreement.

Providers may be responsible for payment if services are denied as not medically necessary or non‑covered
Obtain written member agreement before performing non‑covered services to avoid balance billing, per participation agreements

Peripheral lesion context

Peripheral pulmonary lesions and small solitary nodules are more difficult to evaluate and have lower bronchoscopy sensitivity, particularly for lesions <1.5 cm (sensitivity may be as low as ~10%).

Clinical implicationBecause sensitivity of flexible bronchoscopy is lower for peripheral lesions, adjuncts such as ENB are proposed to increase diagnostic yield for these nodules.

Fiducial marker placement via electromagnetic navigational bronchoscopy — definition

DefinitionPlacement of fiducial markers via electromagnetic navigation bronchoscopy involves loading markers into the navigation catheter and delivering them through the catheter to the target tumor under navigation guidance.

PurposeFacilitates accurate localization of tumors for subsequent image-guided radiotherapy (e.g., stereotactic radiosurgery or stereotactic body radiation therapy).

Evidence / feasibilityPublished feasibility and safety studies report successful fiducial placement and acceptable retention/migration characteristics when placed using ENB.