Priority Health Lung Volume Reduction Coverage

Coverage and Medical Necessity Criteria

Lung Volume Reduction Surgery (LVRS) — Medical Necessity

LVRS is considered medically necessary when ALL of the following criteria are met:

LVRS overall

Anatomic emphysema distribution: Either severe upper lobe emphysema OR severe non-upper lobe emphysema with low exercise capacity
Pulmonary rehabilitation: Pre-operative: 6-10 week series of at least 16 and no more than 20 preoperative sessions each lasting a minimum of two hours; Post-operative: at least 6 and no more than 10 postoperative sessions each lasting a minimum of two hours within 8 to 9 weeks of LVRS. Program must include required components (medical/psychosocial/nutritional evaluation; goal setting for education and exercise training; exercise training including lower extremity, flexibility, strengthening, and upper extremity; education about emphysema and medical treatments; psychosocial counseling; nutritional counseling).
Pulmonary rehabilitation program must include specified components per policy.
Radiographic and physiologic criteria: Radiographic evidence of moderate to severe bilateral emphysema; FEV1 <45% predicted (or >15% predicted if age >70 years); non-smoking for at least 4 months; participation in pulmonary rehabilitation with attainment of preset performance goals (e.g., ability to complete three minute unloaded pedaling).
Exclusions for LVRS: Patient must NOT have any of the following: previous LVRS or lobectomy; be a high-risk patient (FEV1 ≤20% predicted combined with homogeneous emphysema on CT or DLCO ≤20% predicted); COPD conditions unsuitable for LVRS (e.g., bronchiectasis, chronic bronchitis, diffuse emphysema judged unsuitable on CT); systemic disease or neoplasia expected to compromise 5-year survival; medical conditions or circumstances likely to prevent completion of required pre- and postoperative pulmonary diagnostic and therapeutic program.
Surgical approach requirement: LVRS must be performed as bilateral excision of damaged lung with stapling via median sternotomy or video-assisted thoracoscopic surgery.

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Bronchoscopic Lung Volume Reduction (BLVR) — Endobronchial Valves

Implantation of FDA-approved endobronchial valves is medically necessary for emphysema only when ALL patient selection criteria are met and NONE of the contraindications are present:

BLVR overall

Patient selection criteria (ALL required): Diagnosis of emphysema confirmed by CT; BMI <35 kg/m2; stable on ≤20 mg prednisone (or equivalent) daily; Residual Volume (RV) ≥175% predicted (≥200% if homogeneous); FEV1 between 15 and 45% predicted; Total Lung Capacity (TLC) ≥100% predicted; DLCO ≥20% predicted; 6-minute walk distance (6MWD) 100-500 m (150-500 m if homogeneous); non-smoker for at least 4 months; completed and submitted preliminary assessment of collateral ventilation within the target lobe using Chartis® Assessment and/or StratX®/SeleCT™ quantitative CT analysis.
Preliminary collateral ventilation assessment (Chartis and/or StratX/SeleCT QCT) is required.
Contraindications (NONE present): Patient must not have any of the following: bronchoscopic procedures contraindicated; evidence of active pulmonary infection; known allergies to Nitinol, Nickel, Titanium, or Silicone; current smoker; large bullae encompassing >30% of either lung; less than 85% fissure integrity in the lobe intended to be treated as measured by quantitative CT fissure analysis or Chartis® Assessment.

Experimental/Investigational/Not Medically Necessary — BLVR modalities

The following are considered experimental, investigational, and/or unproven and not medically necessary:

Not medically necessary procedures: Endobronchial coils (including PneumRx and similar devices) and other listed unproven BLVR modalities

These procedures are considered experimental/investigational due to insufficient published evidence.

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Priority Health considers endobronchial coils (including PneumRx) to be experimental, investigational, and/or unproven and therefore not medically necessary due to insufficient published evidence to assess safety or impact on health outcomes.

The reference and bibliography portion of the document does not list any additional explicit exclusions beyond those presented in the policy criteria and exclusions sections.

Any of the BLVR techniques explicitly identified in the exclusions — for example, endobronchial coils (including PneumRx) — are considered experimental, investigational, and/or unproven and therefore not medically necessary for Priority Health members.

Within the cited reference and bibliography pages there are no standalone statements repeating a general not medically necessary designation beyond the exclusions and criteria sections; the references list trial citations and past review dates without separate coverage determinations.

Billing and Diagnosis Codes

Covered CPT Codes and Surgical CodesCPTCovered

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 sizing, and insertion of bronchial valve(s), each additional lobe (List separately in addition to code for primary procedure[s])
32141	Thoracotomy; with resection-plication of bullae, includes any pleural procedure when performed
32491	Removal of lung, other than total pneumonectomy; excision-plication of emphysematous lung(s) (bullous or non-bullous) for lung volume reduction, sternal split or transthoracic approach, with or without any pleural procedure
32655	Thoracoscopy, surgical; with resection-plication of bullae, includes any pleural procedure when performed
32672	Thoracoscopy, surgical; with resection-plication for emphysematous lung (bullous or non-bullous) for lung volume reduction (LVRS), unilateral includes any pleural procedure, when performed

Facility-only HCPCS/G-codes for LVRS preparation and follow-upHCPCSCovered

G0302	Preoperative pulmonary surgery services for preparation for LVRS, complete course of services, to include a minimum of 16 days of services
G0303	Preoperative pulmonary surgery services for preparation for LVRS, 10 to 15 days of services
G0304	Preoperative pulmonary surgery services for preparation for LVRS, 1 to 9 days of services
G0305	Post discharge pulmonary surgery services after LVRS, minimum of 6 days of services

ICD-10 Diagnosis Codes that may support medical necessityICD-10

J43.0-J43.9

Emphysema

Physiologic and functional thresholds (selection criteria)

FEV1 (LVRS)FEV1 <45% predicted (or >15% predicted if age >70)

DLCO (BLVR)DLCO ≥20% predicted

Residual Volume (RV) (BLVR)RV ≥175% predicted (≥200% if homogeneous)

Total Lung Capacity (TLC) (BLVR)TLC ≥100% predicted

6-minute walk distance (6MWD) (BLVR)6MWD 100–500 m (150–500 m if homogeneous)

Body Mass Index (BLVR)BMI <35 kg/m2

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization and Individual Case Review

Prior Authorization Required. Prior authorization may be required for LVRS and bronchoscopic lung volume reduction (BLVR). When prior authorization is required, providers must submit documentation demonstrating that the requested drug, device, service, or procedure is medically necessary.

Prior authorization may be required for LVRS and BLVR.
When prior authorization is required, submit request demonstrating medical necessity per Priority Health Provider Manual.
Individual case review may be available for investigational but promising therapies; prior plan approval required for individual consideration.

Documentation Required

Coding and Diagnosis Documentation

Documentation and Coding. Include appropriate CPT/HCPCS and supporting ICD-10 codes to support medical necessity when submitting requests. Examples of supporting diagnosis codes include J43.0–J43.9 (Emphysema). Relevant procedure codes include codes for bronchoscopic valve procedures (e.g., 31647–31651), LVRS and related surgical codes (e.g., 32141, 32491, 32655, 32672), and facility-level pre/postoperative pulmonary service codes (G0302–G0305).

Clinical Background and Rationale

Lung volume reduction surgery (LVRS) removes nonfunctional emphysematous lung tissue (for example, bullae resection and stapling) to reduce hyperinflation and improve respiratory mechanics. In appropriately selected patients LVRS can improve exercise capacity, symptoms, and may improve survival, but it carries significant early perioperative risk and requires careful candidate selection.

Priority Health’s coverage criteria require bilateral resection for LVRS via median sternotomy or video-assisted thoracoscopic surgery, demonstration of radiographic moderate-to-severe bilateral emphysema, and physiologic thresholds including FEV1 <45% predicted (or >15% predicted if age >70). Candidates must be non-smokers for at least 4 months and must complete a structured pulmonary rehabilitation program (preoperative course of 16–20 sessions and specified post-operative sessions) with documented achievement of preset performance goals.

Because LVRS confers measurable benefit only in a narrowly defined subgroup, the policy also specifies exclusions (for example, very low FEV1 or DLCO ≤20% predicted, prior lobectomy/LVRS, diffuse emphysema not amenable to resection, or comorbid conditions limiting life expectancy) to avoid exposing high-risk patients to unacceptable surgical morbidity.

Proprietary Assessment Tools and Definitions

Proprietary quantitative tools and services for BLVR candidate assessment

Chartis® SystemProprietary bronchoscopic assessment tool providing flow and pressure readings to evaluate collateral ventilation in specific lobes (used to select candidates for Zephyr valves)

StratX®Cloud-based quantitative CT analysis platform that reports emphysema destruction, fissure completeness, and lobar volumes to support Zephyr valve patient selection

SeleCT™ QCT analysis serviceOlympus quantitative CT analysis service to quantify emphysema distribution, severity of destruction, and fissure integrity for Spiration valve eligibility assessment

OpenPayer

Lung Volume Reduction (Surgical and Non-Surgical)

Coverage and Medical Necessity Criteria

Billing and Diagnosis Codes

Provider Requirements, Prior Authorization, and Documentation

Clinical Background and Rationale

Proprietary Assessment Tools and Definitions