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    v1.0.30
    OpenPayerPolicy UpdatesVascular/Cardiothoracic SurgeryDHA LVRS Coverage Criteria Policy Update | OpenPay…
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    CurrentDHAPolicy 5.0

    Lung Volume Reduction Surgery (LVRS)

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    This document identifies the DHA policy section governing lung volume reduction surgery within the Surgery chapter of the TRICARE Policy Manual.

    Policy Summary
    PayerDHA
    PolicyLung Volume Reduction Surgery (LVRS)
    Policy CodePolicy 5.0
    Change TypeNo material change
    Effective DateMar 22, 2004
    Next Review DateN/A
    Key ActionBefore performing covered LVRS, establish that the patient meets all selection criteria, has no contraindication or exclusion, completes the required perioperative program, and will be treated at a qualifying facility.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    ≤45%Maximum eligible FEV1
    >140 mMinimum six-minute walk
    16–20Preoperative rehabilitation
    6–10Postoperative rehabilitation
    Bilateral excisionCovered surgical scope

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    Laser bullectomyExcluded procedure

    LVRS Coverage Criteria

    Covered LVRS

    Covered when ALL of the following are met.

    Covered LVRS selection criteria

    • Clinical and behavioral requirements

      • History and physical examination are consistent with emphysema.
      • The patient has not smoked for four or more months.No smoking for ≥ 4 months
      • For a patient with cardiac ejection fraction less than 45%, there is no history of congestive heart failure or myocardial infarction within six months before consideration for surgery.Ejection fraction < 45%; no CHF or MI within 6 months

    • Preoperative workup

      • Pulmonary function: The maximum of the pre- and post-bronchodilator FEV1 is no more than 45% of predicted; if the patient is age 70 or older, FEV1 is at least 15% of predicted. Post-bronchodilator TLC is at least 100% of predicted, and RV is at least 150% of predicted.FEV1 ≤ 45%; age ≥ 70 FEV1 ≥ 15%; TLC ≥ 100%; RV ≥ 150%
      • Gas exchange: Resting PaO2 is at least 44 mm Hg and resting PaCO2 is no more than 60 mm Hg on room air.PaO2 ≥ 44 mm Hg; PaCO2 ≤ 60 mm Hg on room air
      • Imaging and tobacco exposure testing: CT scan demonstrates bilateral emphysema, and plasma cotinine is no more than 13.7 ng/ml when the patient is not using nicotine products or carboxyhemoglobin is no more than 2.5% when the patient is using nicotine products.Cotinine ≤ 13.7 ng/ml or carboxyhemoglobin ≤ 2.5%

    Contraindications and exclusion criteria

    Not covered when any applicable contraindication or exclusion is present.

    Contraindications and exclusions

    • Very severe physiologic disease with unfavorable pattern

      • Post-bronchodilator FEV1 is 20% or less of predicted.FEV1 ≤ 20% of predicted

      • Unfavorable disease pattern

        • CT scan shows a homogeneous distribution of emphysema.
        • DLCO is 20% or less of predicted.DLCO ≤ 20% of predicted

    • Non-upper-lobe disease with high workload

    Procedure, rehabilitation, and facility requirements

    Covered LVRS is additionally subject to the following procedural, rehabilitation, and facility requirements.

    • Covered surgical approach: The procedure is limited to bilateral excision of damaged lung with stapling performed via median sternotomy or video-assisted thoracoscopic surgery.

    • Perioperative diagnostic and therapeutic program

      • Preoperative program: A six- to 10-week series includes at least 16 and no more than 20 preoperative sessions, each lasting at least two hours.Six to 10 weeks; 16-20 sessions; ≥ 2 hours per session
      • Postoperative program: The program includes at least 6 and no more than 10 postoperative sessions, each lasting at least two hours, within eight to nine weeks of LVRS.6-10 sessions within 8-9 weeks; ≥ 2 hours per session

    Thoracoscopic laser bullectomy is excluded from coverage.

    Codes and Clinical Thresholds

    Covered CPT CodesCPTCovered
    32491LVRS procedure code
    Covered HCPCS CodesHCPCSCovered
    G0302HCPCS procedure code
    G0303HCPCS procedure code
    G0304HCPCS procedure code
    G0305HCPCS procedure code
    Smoking abstinence
    Required abstinenceFour or more months
    Smoking statusPatient has not smoked
    ApplicationRequired for LVRS selection
    Cardiac ejection fraction condition
    Ejection fraction triggerLess than 45%
    Heart failureNo history of congestive heart failure within six months of consideration for surgery
    Myocardial infarction

    Provider Requirements and Denial Risks

    Prior Authorization

    Pre-procedure Medical Necessity Review

    Before requesting coverage for LVRS, establish and document every applicable selection criterion, contraindication, and exclusion. Coverage applies only when the patient meets the required clinical profile and the procedure is performed within the policy limits.

    • Confirm severe upper-lobe-predominant emphysema or severe non-upper-lobe emphysema with low exercise capacity.
    • Document that all selection criteria and exclusion requirements have been reviewed before surgery.
    Documentation Required

    Clinical Selection Documentation

    Submit clinical documentation supporting the patient's LVRS selection, including the history, examination, smoking status, cardiac assessment, and clinical rationale.

    • History and physical examination consistent with emphysema.
    • No smoking for at least four months.

    Clinical Background

    Lung volume reduction surgery (LVRS) is a palliative operation for patients with late-stage emphysema. The procedure removes approximately 20% to 30% of lung tissue from one or both lungs to reduce thoracic lung volume and improve ventilation of the remaining lung. LVRS may be performed simultaneously or sequentially through video-assisted thoracoscopic surgery or open median sternotomy, using stapling. Coverage focuses on severe upper-lobe-predominant emphysema or severe non-upper-lobe emphysema accompanied by low exercise capacity.

    Policy Definitions

    Lung volume reduction surgery (LVRS)
    ProcedureA palliative surgical procedure for late-stage emphysema
    PurposeRemoves a large volume of lung tissue to improve ventilation of the remaining lung
    Alternate namesReduction pneumoplasty; lung shaving; lung contouring
    High maximal workload
    Measurement methodMaximal workload measured during cycle ergometry
    Workload increments5 or 10 W per minute
    ProtocolAfter three minutes of pedaling with the ergometer set at 0 W while breathing 30% oxygen
    Policy Summary
    PayerDHA
    PolicyLung Volume Reduction Surgery (LVRS)
    Policy CodePolicy 5.0
    Change TypeNo material change
    Effective DateMar 22, 2004
    Next Review DateN/A
    Key ActionBefore performing covered LVRS, establish that the patient meets all selection criteria, has no contraindication or exclusion, completes the required perioperative program, and will be treated at a qualifying facility.
    SourceLink
    On This Page
    LVRS Coverage CriteriaCodes and Clinical ThresholdsProvider Requirements and Denial RisksClinical BackgroundPolicy Definitions
    Exercise capacity: The six-minute walk test is greater than 140 meters.> 140 meters
    • The patient has predominantly non-upper-lobe emphysema.

      This includes disease judged on CT to be predominantly lower-lobe, diffuse, or predominantly affecting the superior segments of the lower lobes.

    • The patient has a high maximal workload measured by cycle ergometry with the specified protocol.> 25 W for women or > 40 W for men

      Measured with 5- or 10-watt-per-minute increments after three minutes of pedaling at 0 watts while breathing 30% oxygen.

  1. Previous LVRS: The patient has undergone previous LVRS.
  2. Pleural or interstitial disease precludes surgery.
  3. Giant bulla: The patient has a giant bulla greater than one-third the volume of the lung in which the bulla is located.> one-third of affected lung volume
  4. Bronchiectasis: The patient has clinically significant bronchiectasis.
  5. Pulmonary nodule: The patient has a pulmonary nodule requiring surgery.
  6. Previous lobectomy: The patient has undergone previous lobectomy.
  7. Uncontrolled hypertension: The patient has uncontrolled hypertension.Systolic > 200 mm Hg or diastolic > 100 mm Hg
  8. Resting oxygen requirement: The patient requires more than 6 liters of oxygen per minute at rest to maintain oxygen saturation of at least 90%.> 6 L/min to maintain saturation ≥ 90%
  9. Recurrent infections: The patient has a history of recurrent infections with clinically significant sputum production.
  10. Recent unplanned weight loss: The patient has had unplanned weight loss greater than 10% within three months before consideration for surgery.> 10% within 3 months
  11. Pulmonary hypertension: The patient has pulmonary hypertension.Mean pulmonary artery pressure ≥ 33 mm Hg on right-heart catheterization or peak systolic pulmonary artery pressure ≥ 44 mm Hg

  12. Significant cardiac rhythm abnormality

    • Resting bradycardia is present.< 50 beats per minute
    • Frequent multifocal PVCs or complex ventricular arrhythmia is present.
    • Sustained SVT is present.
  13. Systemic disease or neoplasia: There is evidence of systemic disease or neoplasia expected to compromise survival.

  14. Qualifying facility

    • The facility is certified by JCAHO under its LVRS Disease Specific Care Certification Program.
    • The facility is approved by Medicare or TRICARE as a lung or heart-lung transplantation facility.
    15. No history of myocardial infarction within six months of consideration for surgery
    FEV1
    FEV1 thresholdMaximum of pre- and post-bronchodilator values ≤ 45% of predicted
    Age-specific conditionFor age 70 or older, FEV1 must be ≥ 15% of predicted
    MeasurementMaximum of pre- and post-bronchodilator FEV1 values
    Total Lung Capacity
    MeasurementPost-bronchodilator total lung capacity (TLC)
    Threshold≥ 100% of predicted value
    Workup statusRequired on preoperative workup
    Residual Volume
    MeasurementResidual volume (RV)
    Threshold≥ 150% of predicted value
    Workup statusRequired on preoperative workup
    Resting PaO2
    MeasurementResting partial pressure of oxygen (PaO2)
    Minimum threshold44 mm Hg or greater
    Test conditionResting measurement
    Resting PaCO2
    MeasurementResting partial pressure of carbon dioxide (PaCO2)
    Maximum threshold≤ 60 mm Hg
    Test conditionOn room air
    Plasma cotinine
    BiomarkerPlasma cotinine
    Threshold≤ 13.7 ng/ml
    Nicotine-product conditionApplies if the patient is not using nicotine products
    Carboxyhemoglobin
    BiomarkerCarboxyhemoglobin
    Threshold≤ 2.5%
    Nicotine-product conditionApplies if the patient is using nicotine products
    Six-minute walk test
    TestSix-minute walk test
    Minimum distanceGreater than 140 meters
    Selection statusRequired exercise-capacity finding
    Very low FEV1 contraindication
    FEV1 exclusion thresholdPost-bronchodilator FEV1 ≤ 20% of predicted
    Emphysema conditionHomogeneous distribution of emphysema on CT scan
    Alternative conditionDLCO ≤ 20% of predicted
    High maximal workload
    Workload definitionHigh maximal workload is above the sex-specific 40th percentile
    Women25 W
    Men40 W
    Giant bulla
    Exclusion thresholdGreater than one-third of the volume of the lung in which the bulla is located
    Affected structureThe lung in which the bulla is located
    StatusListed exclusion criterion
    Uncontrolled hypertension
    Systolic thresholdGreater than 200 mm Hg
    Diastolic thresholdGreater than 100 mm Hg
    Coverage statusListed exclusion criterion
    Resting oxygen requirement
    Oxygen-flow exclusionGreater than 6 liters per minute during rest
    Oxygen saturation targetTo keep oxygen saturation ≥ 90%
    Coverage statusListed exclusion criterion
    Recent unplanned weight loss
    Weight-loss thresholdGreater than 10%
    Time periodWithin three months prior to consideration for surgery
    TypeUnplanned weight loss
    Pulmonary hypertension
    Diagnostic methodRight-heart catheterization
    Mean pulmonary artery pressure≥ 33 mm Hg
    Alternative pressure criterionPeak systolic pulmonary artery pressure ≥ 44 mm Hg
    Resting bradycardia
    Heart-rate thresholdLess than 50 beats per minute
    MeasurementResting heart rate
    Coverage statusListed exclusion criterion
    Preoperative program
    Program durationSix- to 10-week series
    Session countAt least 16 and no more than 20 preoperative sessions
    Session lengthEach session lasts a minimum of two hours
    Postoperative program
    Session countAt least six and no more than 10 postoperative sessions
    Session lengthEach session lasts a minimum of two hours
    TimingWithin eight to nine weeks of LVRS
  15. If ejection fraction is less than 45%, no congestive heart failure or myocardial infarction within six months before consideration for surgery.
  16. Document the applicable emphysema distribution and exercise-capacity rationale for selection.
    17. Documentation Required

    Imaging, Physiologic Testing, and Exclusion Documentation

    Document the complete preoperative imaging and physiologic evaluation, including all required thresholds and testing used to identify contraindications or exclusions.

    • FEV1 (maximum pre- or post-bronchodilator value) ≤45% predicted; for patients age 70 or older, FEV1 must be ≥15% predicted.
    • Post-bronchodilator TLC ≥100% predicted and RV ≥150% predicted.
    • Resting PaO2 ≥44 mm Hg and room-air PaCO2 ≤60 mm Hg.
    • CT evidence of bilateral emphysema.
    • Plasma cotinine ≤13.7 ng/mL when not using nicotine products, or carboxyhemoglobin ≤2.5% when using nicotine products.
    • Six-minute walk distance >140 meters.
    • Document DLCO, maximal workload testing when applicable, and preoperative testing relevant to contraindications and exclusions.
    Documentation Required

    Perioperative Rehabilitation Documentation

    Document the diagnostic and therapeutic rehabilitation program required before and after LVRS. The program must be consistent with services provided in the National Emphysema Treatment Trial (NETT).

    • Preoperative program: six to 10 weeks, at least 16 and no more than 20 sessions, with each session lasting at least two hours.
    • Postoperative program: at least six and no more than 10 sessions, each lasting at least two hours, completed within eight to nine weeks of LVRS.
    • The program must be designed to maximize the patient's ability to undergo and recover from surgery.
    Prior Authorization

    Facility Qualification

    Verify and document that the facility satisfies one of the policy's qualifying requirements before performing LVRS.

    • JCAHO-certified under the LVRS Disease Specific Care Certification Program, using the applicable program standards and requirements; or
    • Approved by Medicare or TRICARE as a lung or heart-lung transplantation facility.

    Unsupported block type: denial_risk242?

    Denial Risk

    Contraindications and Exclusion Criteria

    Review the contraindications and exclusion criteria before authorization. The listed conditions create a coverage denial risk and must be documented as absent when applicable.

    • Post-bronchodilator FEV1 ≤20% predicted with either homogeneous emphysema on CT or DLCO ≤20% predicted.
    • Predominantly non-upper-lobe emphysema with high maximal workload; high workload is above the sex-specific 40th percentile during the specified cycle-ergometry protocol (25 W for women, 40 W for men).
    • Exclusions include previous LVRS, pleural or interstitial disease precluding surgery, giant bulla greater than one-third of the involved lung, clinically significant bronchiectasis, pulmonary nodule requiring surgery, previous lobectomy, uncontrolled hypertension, oxygen requirement >6 L/min at rest to maintain saturation ≥90%, recurrent infections with clinically significant sputum, unplanned weight loss >10% in three months, pulmonary hypertension, specified bradycardia or arrhythmias, and systemic disease or neoplasia expected to compromise survival.
    Prior Authorization

    Required Rehabilitation and Facility Eligibility

    Confirm both program and facility eligibility before scheduling or billing LVRS. The rehabilitation sequence and the NETT-consistent facility requirements are conditions of covered treatment.

    • Provide the required six- to 10-week preoperative and eight- to nine-week postoperative programs with the policy-defined session counts and durations.
    • Perform LVRS only at a JCAHO LVRS Disease Specific Care-certified facility or a Medicare- or TRICARE-approved lung or heart-lung transplantation facility.
    • Retain records demonstrating program participation and facility qualification.
    Denial Risk

    Excluded Procedure

    Thoracoscopic laser bullectomy is specifically excluded from coverage under this policy.

    • Do not submit thoracoscopic laser bullectomy as a covered LVRS procedure.
    Predominantly non-upper-lobe emphysema
    Imaging methodDisease classification on CT scan
    Radiologist assessmentJudged as predominantly lower-lobe, diffuse, or predominantly affecting the superior segments of the lower lobes
    Upper-lobe distinctionExcludes disease judged to affect primarily the upper lobes
    Giant bulla
    DefinitionA bulla greater than one-third the volume of the lung in which it is located
    Affected structureThe lung in which the bulla is located
    Policy statusListed as an exclusion criterion