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ModifiedCurativePolicy CHP-IP-2026-173

Decortication, Pleurectomy, and Surgical Pleurodesis

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Inpatient medical-necessity and level-of-care criteria for open or thoracoscopic decortication, pleurectomy, and surgical pleurodesis for Curative commercial PPO and EPO members, including empyema, trapped lung or fibrothorax, malignant pleural effusion, recurrent or persistent pneumothorax, and retained hemothorax.

Policy Summary

PayerCurative

PolicyDecortication, Pleurectomy, and Surgical Pleurodesis

Policy CodePolicy CHP-IP-2026-173

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionSubmit imaging, pleural-fluid studies, drainage and fibrinolytic history, operative documentation, and level-of-care records to support the requested service and duration.

SourceLink

POLICY UPDATE CHANGES

The empyema criteria no longer require failure of both chest tube drainage and intrapleural fibrinolytics in every case; drainage and antibiotics may be sufficient when persistent sepsis, residual collection, or an undrainable loculation remains.

The policy adopts recurrence-prevention indications for surgery after a second ipsilateral or first contralateral spontaneous pneumothorax and for selected high-risk first episodes.

For malignant pleural effusion, surgical talc pleurodesis is limited to recurrent symptomatic effusion with an expandable lung when pleurodesis is selected over an indwelling pleural catheter.

The policy clarifies applicable coding, including laterality for ICD-10-PCS pleural release and the distinction between thoracoscopic partial decortication and pleurodesis CPT codes.

The policy replaces the prior requirement that empyema cases must fail both chest-tube drainage and fibrinolytics in every case.

The policy adopts guideline-based indications for malignant pleural effusion and pneumothorax surgical management.

All agesApplicable population

5.9 / 3.2 / 1.9 daysMajor chest procedure length-of-stay benchmarks

SpO2 ≥92%Discharge oxygenation threshold

>5 daysExtended-stay air-leak trigger

10ICD-10-CM codes listed

9CPT codes listed

Inpatient Coverage and Level-of-Care Criteria

Inpatient admission

Covered when ALL of the following are met: at least one procedure indication and at least one inpatient-setting requirement.

Inpatient admission medical necessity

Procedure indications
- Empyema or complicated parapneumonic effusion: Stage II or III empyema or complicated parapneumonic effusion with persistent sepsis or a residual collection despite chest tube drainage and antibiotics, with or without intrapleural fibrinolytic therapy, or a loculated collection not amenable to drainage.
- Trapped lung or fibrothorax with symptomatic restriction, including dyspnea with restrictive physiology or volume loss on imaging, persisting at least several weeks after infection or hemothorax.At least several weeks

Policy Summary

PayerCurative

PolicyDecortication, Pleurectomy, and Surgical Pleurodesis

Policy CodePolicy CHP-IP-2026-173

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionSubmit imaging, pleural-fluid studies, drainage and fibrinolytic history, operative documentation, and level-of-care records to support the requested service and duration.

SourceLink

On This Page

Malignant pleural effusion: Recurrent symptomatic malignant pleural effusion with expandable lung when thoracoscopic talc pleurodesis is chosen over an indwelling pleural catheter.

Spontaneous pneumothorax: Second ipsilateral or first contralateral episode; bilateral simultaneous pneumothorax; tension pneumothorax; hemopneumothorax; persistent air leak or failure of lung re-expansion despite drainage; or first episode in a high-risk occupation.

Retained hemothorax not cleared by chest tube drainage.

Inpatient setting required

Procedure and chest tube monitoring: Open thoracotomy, sternotomy, or thoracoscopic/robotic procedure with a chest tube requiring postoperative monitoring of air leak and drainage.
Postoperative analgesia requiring an epidural, paravertebral catheter, or intravenous patient-controlled analgesia.
Patient risk or comorbidity: ASA physical status III or IV, or a comorbidity requiring postoperative monitoring or management beyond an ambulatory or observation setting, such as heart failure, chronic kidney disease, poorly controlled diabetes, obstructive sleep apnea on therapy, or anticoagulation bridging.ASA III or IV
Active pleural infection with sepsis requiring intravenous antibiotics.

Observation or outpatient instead of inpatient

Observation or outpatient care is appropriate when ANY of the following applies.

Observation or outpatient level

Indwelling pleural catheter placement for malignant effusion or non-expandable lung is outpatient.
First primary spontaneous pneumothorax managed conservatively or by ambulatory drainage without a recurrence-prevention indication.

Intensive care unit

ICU placement is appropriate when ANY of the following is present.

Ventilation or airway: Mechanical ventilation, airway concern after airway or mediastinal surgery, or need for vasopressors.
Hemorrhage or hypoxemia: Hemorrhage requiring transfusion of more than 2 units in 4 hours or re-exploration, or SpO2 below 90% despite high-flow oxygen or noninvasive ventilation.
Unstable arrhythmia: New arrhythmia with hemodynamic instability.

Step-down or intermediate care

Step-down or intermediate care is appropriate when ANY of the following is present and no ICU criterion is met.

Step-down or intermediate care: Use step-down or intermediate care for the first postoperative night after extensive resection with continuous pulse oximetry and telemetry, epidural or paravertebral analgesia requiring frequent respiratory and hemodynamic monitoring, or new atrial fibrillation requiring intravenous rate control, provided no ICU criterion is met.

Medical-surgical unit

Medical-surgical placement is appropriate when ANY of the following describes the patient and no higher-level criterion is met.

Medical-surgical unit: Stable vital signs on room air or low-flow oxygen with chest tube management, oral analgesia transition, and early mobilization, when no higher-level criterion is met.

Discharge readiness

Discharge from acute inpatient care is appropriate when ALL of the following are met.

Hemodynamic and temperature stability: Hemodynamically stable for at least 24 hours without intravenous vasoactive agents, and temperature below 38.0°C for at least 24 hours or a fever source identified and treated.24 hours; temperature below 38.0°C
Oxygenation: SpO2 92% or higher on room air or the patient's baseline home oxygen.SpO2 >= 92%
Symptoms and function: Pain controlled on an oral regimen, oral diet tolerated or a stable enteral/parenteral plan established, and voiding.
Mobility and post-acute setting: Ambulating at the expected post-procedure level or a skilled post-acute setting arranged.
Wound and drains: Wound is clean without deep infection; drains are removed or a home drain-care plan is in place.
Laboratory stability: Hemoglobin, creatinine, and electrolytes are stable.
Medication and follow-up planning: Medication reconciliation is complete, including venous thromboembolism prophylaxis and any anticoagulation plan, and surgeon follow-up is arranged, commonly within 7 to 14 days.7 to 14 days commonly
Chest tube and imaging status: Chest tubes are removed with no enlarging pneumothorax or effusion on follow-up imaging, or the patient is discharged with a portable drainage device and documented follow-up plan.
Empyema-specific readiness: For empyema, the patient is afebrile with falling inflammatory markers and an oral or outpatient intravenous antibiotic plan with defined duration.

Continued acute inpatient stay

Continued acute inpatient stay is medically necessary when ANY of the following is documented at concurrent review.

Continued-stay criteria

Hemodynamic or respiratory instability, or ongoing need for intravenous vasoactive agents, ventilation, or supplemental oxygen above baseline that cannot be provided at a lower level.
Postoperative complication requiring acute hospital treatment, including bleeding, infection, arrhythmia, venous thromboembolism, acute kidney injury, ileus, or delirium.
Acute intravenous therapy: Intravenous medications, fluids, or nutrition that cannot safely be given at a lower level of care.
Pending urgent service: Pending urgent procedure or imaging requiring inpatient status.
Persistent pleural or lung problem: Persistent air leak, undrained infected space, or incomplete lung re-expansion requiring continued chest tube management.
Extended-stay complications: Air leak persisting beyond 5 days, pneumonia or empyema requiring ongoing treatment, atrial fibrillation requiring intravenous therapy, chylothorax, recurrent laryngeal or phrenic nerve injury with aspiration risk, or respiratory failure.Air leak beyond 5 days

Clinical evidence and rationale

Empyema clinical indications: Stage III empyema with a fibrous peel supports decortication; VATS is supported for earlier stages when drainage fails.

These indications replace the prior requirement for failed chest tube drainage and fibrinolytics in every case.

Malignant pleural effusion clinical indications: Catheter or talc pleurodesis is supported for an expandable lung; catheter alone is supported for a non-expandable lung.

These indications define when inpatient surgical pleurodesis is appropriate.

Pneumothorax clinical indications: BTS 2023 recurrence-prevention indications are adopted.

Specific recurrence-prevention criteria are not reproduced in this document window.

This policy addresses inpatient criteria for open or thoracoscopic decortication, pleurectomy, and surgical pleurodesis for empyema, trapped lung or fibrothorax, malignant pleural effusion, recurrent or persistent pneumothorax, and retained hemothorax. Bedside chest tube placement, intrapleural fibrinolytic therapy, outpatient indwelling pleural catheter placement, and pleural mesothelioma radical resection are outside the scope of this policy.

A first primary spontaneous pneumothorax managed conservatively or by ambulatory drainage, without a recurrence-prevention indication, is appropriately managed at the observation or outpatient level rather than through inpatient surgical admission.

Talc pleurodesis is not medically necessary for malignant pleural effusion with a non-expandable lung when an indwelling pleural catheter is preferred. Such requests are referred for physician review.

Surgery after a first uncomplicated primary spontaneous pneumothorax is not medically necessary when no recurrence-prevention indication is present. The request is referred for physician review.

A pre-operative admission solely for testing, bowel preparation, or convenience is not medically necessary when medical optimization is not required, such as anticoagulation bridging, heart-failure optimization, or dialysis. Same-day admission is the standard in this circumstance, subject to physician review when criteria are not met.

Continued acute inpatient days after discharge readiness is achieved do not meet acute inpatient criteria when used solely to await skilled nursing, rehabilitation, long-term acute care, behavioral health, or home-services placement, or for custodial care, family or provider convenience, or scheduling non-urgent tests or consultations that can safely occur at a lower level of care or after discharge. These days require physician review and active discharge planning; previously authorized days are not retroactively denied.

Billing and Reference Codes

ICD-10-CMICD-10

J86.0	ICD-10-CM code listed for reference
J86.9	ICD-10-CM code listed for reference
J91.0	ICD-10-CM code listed for reference
J94.0	ICD-10-CM code listed for reference
J94.1	ICD-10-CM code listed for reference
J94.2	ICD-10-CM code listed for reference
J93.0	ICD-10-CM code listed for reference
J93.11	ICD-10-CM code listed for reference
J93.12	ICD-10-CM code listed for reference
J93.82	ICD-10-CM code listed for reference

ICD-10-PCSICD-10

0BNN0ZZ	Release of right pleura, open
0BNP0ZZ	Release of left pleura, open
0BNN4ZZ	Release of right pleura, percutaneous endoscopic
0BNP4ZZ	Release of left pleura, percutaneous endoscopic
0BBN0ZZ	Excision of right pleura, open
0BBP0ZZ	Excision of left pleura, open
0BBN4ZZ	Excision of right pleura, percutaneous endoscopic
0BBP4ZZ	Excision of left pleura, percutaneous endoscopic

CPTCPT

32220	Open decortication
32225	Decortication with parietal pleurectomy
32320	Open decortication or related pleural procedure
32650	Thoracoscopic pleurodesis
32651	Thoracoscopic partial decortication
32652	Thoracoscopic decortication, pleural procedure
32653	Thoracoscopic pleural procedure
32655	Thoracoscopic bullectomy or related pleural procedure
32656	Thoracoscopic hemothorax or fibrin removal

MS-DRG (FY 2027 v44)Revenue

163	MS-DRG FY 2027 v44
164	MS-DRG FY 2027 v44
165	MS-DRG FY 2027 v44
166	MS-DRG FY 2027 v44
167	MS-DRG FY 2027 v44
168	MS-DRG FY 2027 v44

Revenue codesRevenue

0120	Revenue code for claim routing reference
0200	Revenue code for claim routing reference
0206	Revenue code for claim routing reference
0360	Revenue code for claim routing reference
0370	Revenue code for claim routing reference

ICD-10-CMICD-10

J86.0
J86.9
J91.0
J94.0
J94.1
J94.2
J93.0
J93.11
J93.12
J93.82

ICD-10-PCSICD-10

0BNN0ZZ	Release of right or left pleura (open; percutaneous endoscopic)
0BNP0ZZ	Release of right or left pleura (open; percutaneous endoscopic)
0BNN4ZZ	Release of right or left pleura (open; percutaneous endoscopic)
0BNP4ZZ	Release of right or left pleura (open; percutaneous endoscopic)
0BBN0ZZ	Excision of right or left pleura
0BBP0ZZ	Excision of right or left pleura
0BBN4ZZ	Excision of right or left pleura
0BBP4ZZ	Excision of right or left pleura

CPTCPT

32220	Open decortication; decortication with parietal pleurectomy; thoracoscopic decortication, pleurodesis, pleurectomy, bullectomy, hemothorax/fibrin removal
32225	Open decortication; decortication with parietal pleurectomy; thoracoscopic decortication, pleurodesis, pleurectomy, bullectomy, hemothorax/fibrin removal
32320	Open decortication; decortication with parietal pleurectomy; thoracoscopic decortication, pleurodesis, pleurectomy, bullectomy, hemothorax/fibrin removal
32650	Open decortication; decortication with parietal pleurectomy; thoracoscopic decortication, pleurodesis, pleurectomy, bullectomy, hemothorax/fibrin removal
32651	Open decortication; decortication with parietal pleurectomy; thoracoscopic decortication, pleurodesis, pleurectomy, bullectomy, hemothorax/fibrin removal
32652	Open decortication; decortication with parietal pleurectomy; thoracoscopic decortication, pleurodesis, pleurectomy, bullectomy, hemothorax/fibrin removal
32653	Open decortication; decortication with parietal pleurectomy; thoracoscopic decortication, pleurodesis, pleurectomy, bullectomy, hemothorax/fibrin removal
32655	Open decortication; decortication with parietal pleurectomy; thoracoscopic decortication, pleurodesis, pleurectomy, bullectomy, hemothorax/fibrin removal
32656	Open decortication; decortication with parietal pleurectomy; thoracoscopic decortication, pleurodesis, pleurectomy, bullectomy, hemothorax/fibrin removal

MS-DRG (FY 2027 v44)Revenue

163
164
165
166
167
168

Revenue codesRevenue

0120
0200
0206
0360
0370

Hypotension red flag

ThresholdSystolic blood pressure below 90 mm Hg or mean arterial pressure below 65 mm Hg despite fluids.

Required responseRapid response and ICU evaluation.

Clinical evaluationEvaluate for bleeding, sepsis, or tamponade.

Lactate red flag

ThresholdNew lactate of 4 mmol/L or higher.

Required responseRapid response and ICU evaluation.

Clinical evaluationEvaluate for bleeding, sepsis, or tamponade when this occurs with hypotension or new vasopressor need.

Oxygen saturation red flag

ThresholdSpO2 below 90% on supplemental oxygen.

Required responseRapid response, airway and ventilatory support, and ICU evaluation.

Safety concernThis finding changes the review pathway and requires urgent handling.

Respiratory rate red flag

ThresholdRespiratory rate above 30 breaths per minute.

Required responseRapid response, airway and ventilatory support, and ICU evaluation.

Related respiratory concernA rising PaCO2 is also identified as a respiratory red flag.

Hemorrhage red flag

Transfusion thresholdMore than 2 units transfused in 4 hours.

Surgical thresholdRe-exploration.

Level of careHemorrhage meeting either threshold supports intensive care unit placement.

Discharge oxygenation

Oxygenation thresholdSpO2 92% or higher.

Room-air conditionThe threshold applies on room air.

Home-oxygen conditionThe threshold also applies on the patient's baseline home oxygen.

Fever and discharge readiness

Temperature thresholdTemperature below 38.0°C for at least 24 hours.

Alternative pathwayAlternatively, the fever source must be identified and treated.

Discharge requirementThe patient must also be hemodynamically stable for at least 24 hours without intravenous vasoactive agents.

Extended-stay air leak

Extended-stay thresholdAir leak persisting beyond 5 days.

Review significanceThis is an extended-stay trigger that can justify days beyond the expected length-of-stay benchmark.

Concurrent review intervalReview is daily in the ICU and at least every 48 hours on other units.

Review, Documentation, and Denial-Risk Rules

Denial Risk

Physician Review Required for Adverse Determinations

Automated systems and non-physician clinical reviewers may approve a request in full or in part but may not issue an adverse determination. Requests that do not meet criteria must be referred to a licensed physician of the same or similar specialty, after offering the requesting provider a peer-to-peer discussion; the reviewing physician must also meet applicable plan and state requirements.

Do not issue an automated or non-physician adverse determination.
Route adverse determinations to same-or-similar-specialty physician review.

Billing Rule

Concurrent Review for Continued Stays

Apply concurrent review to each continued-stay period. Days already authorized must not be retroactively denied; an expected length of stay is a planning benchmark, not a limit on covered days.

Review each continued-stay period separately.
Do not retroactively deny previously authorized days.
The Medicare two-midnight benchmark is not a coverage criterion for these commercial plans.

Documentation Required

Required Clinical Documentation

Submit clinical documentation supporting the requested procedure and level of care, including imaging, pleural fluid studies, treatment history, operative information, and continued-stay or discharge documentation when applicable.

Chest CT and/or ultrasound showing loculation, peel, or re-expansion status.
Pleural fluid pH, glucose, LDH, culture, and cytology.
Drainage and fibrinolytic therapy history; pneumothorax episode history and occupation when relevant.
ASA physical status and relevant comorbidities.
Operative note with approach and intraoperative events.
Daily progress notes supporting level of care, complications, and the reason for continued stay when expected length of stay is exceeded.
Discharge-readiness assessment and post-acute plan.

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Denial Risk

Pleurodesis When Catheter Is Preferred

Flag talc pleurodesis requests for malignant effusion when the lung is non-expandable. An indwelling pleural catheter is preferred in this circumstance; refer the request for physician review rather than issuing an automated denial.

Scenario: malignant effusion with non-expandable lung.
Reason: an indwelling pleural catheter is preferred.

Denial Risk

Unindicated First-Episode Pneumothorax Surgery

Identify surgery after a first uncomplicated primary spontaneous pneumothorax when there is no recurrence-prevention indication. Refer the request for physician review as not medically necessary under this policy.

Applies to a first uncomplicated primary spontaneous pneumothorax.
Confirm whether a recurrence-prevention indication exists.

Denial Risk

Convenience Pre-Admission

Identify pre-operative admission the day before surgery when it is solely for testing, bowel preparation, or convenience and no medical optimization is required. Same-day admission is standard in these circumstances; refer the request for physician review.

Examples of qualifying medical optimization include intravenous-heparin anticoagulation bridging, heart-failure optimization, or dialysis.
Do not treat convenience, testing, or bowel preparation alone as medical optimization.

Denial Risk

Stay After Discharge Readiness

Identify continued post-operative acute inpatient days after all discharge-readiness criteria are met. Refer for physician review and discharge planning when no acute hospital-level service remains necessary.

Assess discharge readiness and the post-acute plan.
Previously authorized days are not retroactively denied.

Denial Risk

Non-Acute Inpatient Days

Identify days used for custodial care, family or provider convenience, or scheduling of non-urgent tests or consultations that could safely occur at a lower level of care or after discharge. Continued acute inpatient days solely while awaiting placement are also lower-level-care circumstances when discharge readiness criteria are met and no acute hospital-level service is being delivered.

Placement examples include skilled nursing, rehabilitation, long-term acute care, behavioral health, or home services.
Refer for physician review and active discharge planning.
Days already authorized are not retroactively denied.

Billing Rule

Reference Codes Do Not Establish Coverage

Codes are listed for reference and routing only; code listing alone does not establish coverage or medical necessity. Coverage remains subject to the member's benefit plan and applicable federal and state law.

ICD-10-CM: J86.0, J86.9, J91.0, J94.0, J94.1, J94.2, J93.0, J93.11, J93.12, J93.82.
ICD-10-PCS: 0BNN0ZZ, 0BNP0ZZ, 0BNN4ZZ, 0BBN0ZZ, 0BBP0ZZ, 0BBN4ZZ, 0BBP4ZZ, and related right- or left-pleura release or excision procedures.
CPT: 32220, 32225, 32320, 32650, 32651, 32652, 32653, 32655, 32656.
Revenue codes: 0120, 0200, 0206, 0360, 0370, 163, 164, 165, 166, 167, 168.

Clinical Background

Empyema generally progresses from an exudative stage I to a fibrinopurulent stage II and then an organized stage III. In stage III, a fibrous pleural peel may prevent the lung from re-expanding and result in a trapped lung. Early VATS decortication is supported for stage II or III disease when drainage and antibiotics fail, while open decortication may be used for advanced organized disease.

Key Definitions and Planning Benchmarks

Trapped (non-expandable) lung

DefinitionA trapped or non-expandable lung cannot re-expand to the chest wall after drainage.

CauseThe inability to re-expand is due to a visceral pleural peel.

Clinical contextThe definition describes lung re-expansion status after drainage.

Expected length of stay

PurposeExpected length of stay is a planning benchmark.

Coverage implicationIt is not a limit on covered days.

Major chest procedure benchmarksFY 2027 geometric mean length of stay is 5.9, 3.2, and 1.9 days for DRGs 163, 164, and 165, respectively.

Other respiratory operating-room benchmarksFY 2027 geometric mean length of stay is 7.6, 3.3, and 1.8 days for DRGs 166, 167, and 168, respectively.