SelectHealth Bronchial Thermoplasty Coverage Update

Coverage Criteria

Diaphragmatic/Phrenic Nerve Pacing - Covered Indication

Covered when ALL of the following are met

Primary coverage condition: Diaphragmatic/phrenic nerve pacing (e.g., NeuRx DPS) is covered for patients with spinal cord injury when clinical selection criteria in the policy are satisfied.

Select Health states current literature demonstrates clinical effectiveness in appropriately selected spinal cord injury patients.

Diaphragmatic/Phrenic Nerve Pacing - Not Covered Indications

Not covered when ANY of the following are present

Investigational indications: Use of diaphragmatic/phrenic nerve pacing for any indication other than spinal cord injury (including amyotrophic lateral sclerosis) is considered experimental/investigational and not covered.

Select Health explicitly states DPS is not covered for other indications including ALS.

Bronchoscopic EBV for severe emphysema (Commercial & CHIP)

Covered when ALL of the following are met:

Main eligibility

Diagnosis: Emphysema confirmed by CT scan
CT confirmation required
Smoking cessation for at least 4 months>=4 months
policy requirement
BMI: Body mass index (BMI) less than 35 kg/m2<35
policy requirement

EBV for bronchopleural / persistent air leaks

Covered when treated for bronchopleural fistulas or prolonged air leaks refractory to standard management:

Air leak indication

Clinical scenario: Treatment of bronchopleural fistulas or persistent/prolonged air leaks refractory to other standard management
IBV Valve System has HDE approval for this indication; limited-duration use (up to 6 weeks) may apply
Supporting data: Evidence consists of small case series and uncontrolled data; documentation that the air leak is refractory to standard treatments is required
policy notes limited evidence

Indications and evidence notes

Evidence-summary and indication-specific guidance summarized in this section (no full criteria tree in these chunks).

Indications discussed: Document references a range of indications and evidence strength: examples include carbon monoxide poisoning (acute symptomatic, treat if started <24 hours), idiopathic sudden sensorineural hearing loss (limited/weak evidence), radiation tissue injury and refractory wounds; evidence strength and recommended use vary by condition.

Summary drawn from HHS review and cited literature

Commercial plan — Adult coverage criteria

Covered when ALL of the following are met

Adult Inspire coverage: 1) Age ≥ 18 years; 2) Moderate-to-severe OSA with AHI 15–100 events/hour; 3) Polysomnography or home sleep testing within 24 months of consult; 4) Central/mixed apneas <25% of all AHI events; 5) Recommendation for Inspire by both an ENT and a sleep specialist; 6) Documentation of CPAP failure (AHI >15 despite CPAP) or CPAP intolerance (defined as <4 hours/night, 5 nights/week) or non-compliance for ≥6 months; 7) No anatomical findings that would compromise device performance; 8) BMI <40 kg/m2; 9) Dental appliance not appropriate or ineffective; 10) Device must be implanted by an ENT.see node text

from policy criteria

Adolescent coverage criteria — Down syndrome

Covered for adolescents with Down syndrome when ALL of the following are met

Adolescent (13–18) Down syndrome coverage: 1) Age 13–18 years; 2) Severe OSA with AHI ≥10 and ≤50; 3) No anatomical findings that would compromise device performance, including no complete concentric collapse at the soft palate by drug-induced sleep endoscopy; 4) Consideration of all other standard treatments; 5) Central and mixed sleep apnea <25% of all AHI events; 6) Documentation of CPAP failure or intolerance (as defined for adults) or non-compliance ≥6 months; 7) Recommendation by both an ENT and a sleep specialist; 8) Device must be implanted by an ENT.see node text

policy criteria for adolescents with Down syndrome

Inspire UAS - Covered with criteria

Coverage criteria for Inspire Upper Airway Stimulation (Commercial Plan) revised

Inspire UAS coverage criteria (revised): Patient meets age criteria (minimum 18 years for general commercial criteria; adolescents with Down Syndrome ages 13–18 have separate criteria); has moderate-to-severe OSA with AHI 15–100 events/hour; polysomnography or home sleep testing within 24 months of consult; BMI <40 kg/m2; documentation of CPAP failure or intolerance or non-compliance as defined in the policy.see thresholds

summarized from revision history and policy updates

MI-E - Covered with criteria

Coverage criteria for Mechanical Insufflation-Exsufflation (Commercial Plan and CHIP)

MI-E coverage criteria: Device is medically necessary for patients with neuromuscular disorders (e.g., muscular dystrophy, amyotrophic lateral sclerosis, spinal muscular atrophy), spinal cord injuries, myasthenia gravis, or significant impairment of chest wall/diaphragmatic movement resulting in difficulty clearing secretions; selection should consider individual physiologic parameters, disease tempo, caregiver availability, and patient preference.clinical judgment

summarized from policy description

MI-E Clinical Evidence Summary

MI-E / CoughAssist clinical summary (informational):

MI-E evidence: Published data suggest MI-E can improve peak cough expiratory flow; evidence consists primarily of case series and patients serving as their own controls with some reports of reduced hospitalizations. Clinical utility depends on lung function, disease tempo, caregiver availability, and patient preference.

informational evidence summary

MESOMARK (SMRP) - Not Covered

MESOMARK test coverage determination:

MESOMARK coverage stance: Select Health Commercial plan does NOT cover the MESOMARK test for mesothelioma; current evidence is inconclusive regarding clinical utility for diagnosis or monitoring.

listed as investigational/experimental/unproven

Initial Therapy

Covered when ALL of the following are met

RFA Medical Necessity Criteria: 1) Isolated peripheral non–small-cell lung cancer lesion or malignant nonpulmonary tumor metastatic to the lung; 2) Tumor size ≤ 3 cm; 3) Tumor located ≥ 1 cm from trachea, main bronchi, esophagus, aorta/aortic arch branches, pulmonary artery, and heart; 4) Surgical resection or radiotherapy with curative intent is considered appropriate but medical comorbidity renders the individual unfit for those interventions OR preservation of lung function is necessary because surgery/radiotherapy would substantially worsen pulmonary status; 5) Individual is not a surgical candidate and there is no evidence of extrapulmonary metastases when indicated; 6) No more than 3 tumors per lung to be ablated; 7) Tumors amenable to complete ablation.see node text

policy criteria

Coverage statement (partial)

Excerpted coverage statements and revision note

Billing header: Covered: For the indications outlined above

indicates coverage for indications described elsewhere in the policy

Covered Indications (Commercial Plan & CHIP)

Covered when ANY of the following pediatric indications are present and the study will alter the treatment plan:

Covered Indications: Obstructive sleep apnea syndrome; evaluation of disturbed sleep patterns/excessive daytime sleepiness/cor pulmonale/failure to thrive/polycythemia when testing will alter treatment; to differentiate primary snoring from pathologic snoring; intensive postoperative monitoring after adenotonsillectomy or other pharyngeal surgery with risk factors (>=10 obstructive events/hr, SaO2 <=70%, neuromuscular disease, craniofacial abnormalities); laryngomalacia with failure to thrive or cor pulmonale; persistent snoring >4 weeks post-op in previously diagnosed OSAS; titration of CPAP/BiPAP after diagnostic PSG; selected indications in bronchopulmonary dysplasia, cystic fibrosis (on supplemental O2 with positive nocturnal oximetry and polycythemia or cor pulmonale), neuromuscular disease, and alveolar hypoventilation.see text

OR logic among listed indications

Use of services, devices, or procedures outside the specific coverage criteria set forth in this policy is considered experimental/investigational and is not covered. Requests for coverage must demonstrate that the patient meets all applicable policy elements (severity, diagnostic testing, and prior medical therapy) or the request may be denied.

Diaphragmatic/phrenic nerve pacing (e.g., NeuRx DPS) is covered only for patients with spinal cord injury. Use of diaphragmatic/phrenic nerve pacing for any other indication, including amyotrophic lateral sclerosis (ALS), is considered experimental/investigational and is not covered.

Routine use of endobronchial valves for emphysema is not recommended where the evidence does not demonstrate a clear net clinical benefit. The available randomized and uncontrolled data are limited and associated with adverse events; therefore valve placement outside the specific, evidence‑based eligibility criteria should be considered investigational/unproven and is not covered.

Select Health does NOT cover high frequency chest wall compression (HFCWO) therapy devices for medical conditions beyond the listed, supported indications (for example, for COPD and other indications where evidence is insufficient). Use for unsupported indications is considered experimental/investigational and will be denied.

Topical hyperbaric oxygen chamber, disposable (HCPCS A4575), is listed as not covered in this policy.

Medicare coverage determinations are made by the Centers for Medicare & Medicaid Services (CMS). If CMS has not adopted a coverage determination for a service and InterQual criteria are not available, the Select Health Commercial policy will apply for determining coverage in Medicare situations unless otherwise specified by CMS.

Mechanical insufflation–exsufflation (MI‑E) devices are not covered for patients with contraindications listed in the MI‑E policy. Specifically, MI‑E is not covered for patients with a history of bullous emphysema, lung cysts, or presence or susceptibility to pneumothorax or pneumomediastinum, or recent barotrauma.

Select Health does NOT cover the MESOMARK (soluble mesothelin-related peptide) test for mesothelioma. Current evidence is inconclusive regarding clinical utility for diagnosis or monitoring; the test is designated investigational/experimental/unproven and not covered.

Radiofrequency ablation (RFA) of pulmonary tumors is considered medically necessary only when the specific criteria in this policy are met. Use of RFA for indications not outlined in the policy or when established criteria (tumor size, location relative to critical structures, surgical candidacy) are not satisfied is considered investigational/experimental/unproven and not covered.

The policy excerpts provided do not list additional explicit exclusion conditions beyond those described; however, the inclusion or exclusion of procedure, diagnosis, or device codes in this policy is informational. Coverage determinations depend on the member's individual benefit plan and do not guarantee coverage or payment.

Coverage under Select Health is limited to the clinical conditions and criteria specifically outlined in this policy. The listing of codes or devices is informational; inclusion or exclusion of codes does not by itself guarantee member coverage. Members and providers must verify benefits against the individual's contract to determine coverage.

The inclusion or exclusion of a procedure, diagnosis, or device code in this policy does not by itself constitute or imply member coverage or guarantee payment. Coverage and reimbursement are determined by the member's contract benefits in effect at the time services are rendered.

Bronchial thermoplasty (BT) is considered investigational/experimental when provided for indications that do not meet the specific coverage criteria detailed in this policy. Requests must meet all required criteria to be considered medically necessary.

The code G12.21 is listed in the policy as Not covered: Investigational/Experimental/Unproven for the indicated use referenced in the document.

Endobronchial valve placement is considered investigational/unproven for indications not specifically enumerated in the coverage criteria because available evidence is limited and safety concerns have been reported; such uses are not covered.

Data are extremely limited for disorders such as COPD and do not support the use of HFCWO vests for that disorder. Consequently, the policy states that evidence does not support routine use of HFCWO vests in COPD.

An HHS review cited in the policy noted that 13% of beneficiaries showed no improvement after hyperbaric oxygen therapy and that a substantial proportion received treatments that likely did not yield maximum benefit—findings the policy uses to justify careful application of HBOT and continued review of progress.

Therapies with low‑quality or limited comparative evidence and without randomized trials or consistent long‑term outcome data are described in the policy as unproven for broad clinical endpoints; until higher-quality evidence is available, such uses are considered unproven or investigational.

Mechanical insufflation–exsufflation (MI‑E) is covered only for patients who meet the neuromuscular or ventilatory insufficiency criteria in the policy. Use of MI‑E for patients who do not meet those specified criteria is not covered.

The MESOMARK assay is designated investigational/experimental/unproven for the indicated use in this policy and is therefore not covered by Select Health.

Use of radiofrequency ablation (RFA) as a primary management strategy for lung tumors when the policy's candidacy criteria (tumor size ≤ 3 cm, appropriate distance from critical structures, and patient unfitness for surgery/radiation) are not met — or when long‑term survival benefit is unproven — is considered investigational and not covered.

The policy excerpts provided do not include an explicit 'not medically necessary' statement for bronchial thermoplasty; coverage language in the document focuses on meeting specific criteria to establish medical necessity.

Other diagnostic techniques (for example, nocturnal pulse oximetry or daytime nap studies) have high false‑negative rates and cannot replace polysomnography when results will affect management. Polysomnography remains the diagnostic standard when definitive testing is required.

Coding and Billing

Covered CPT CodesCPTCovered

31660	Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe
31661	Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes

Covered CPT Codes for EBV proceduresCPTCovered

31647	Bronchoscopy with balloon occlusion, assessment of air leak, airway sizing, and insertion of bronchial valve(s), initial lobe
31648	Bronchoscopy with removal of bronchial valve(s), initial lobe
31649	Bronchoscopy with removal of bronchial valve(s), each additional lobe
31651	Bronchoscopy with balloon occlusion, assessment of air leak, airway sizing, and insertion of bronchial valve(s), each additional lobe

Covered CPT Codes (Pacing implantation / Neurostimulator procedures)CPTCovered

64580	Incision for implantation of neurostimulator electrode array; neuromuscular
64590	Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver; direct or inductive coupling
64582	Open implantation of hypoglossal nerve neurostimulator array, pulse generator; and distal respiratory sensor electrode or electrode array
64583	Revision or replacement of hypoglossal nerve neurostimulator array and distal respiratory sensor electrode or electrode array, including connection to existing pulse generator
64568	Incision for implantation of cranial nerve neurostimulator electrode array and pulse generator
64569	Revision or replacement of cranial nerve neurostimulator electrode array, including connection to existing pulse generator
64570	Removal of cranial nerve neurostimulator electrode array and pulse generator
64582	Open implantation of hypoglossal nerve neurostimulator array (listed again for completeness)
64583	Revision or replacement of hypoglossal nerve neurostimulator array (listed again for completeness)
64590	Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver; direct or inductive coupling (listed)

Relevant CPT Codes for Sleep and NeurostimulationCPT

95805	Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation
95807	Sleep study, simultaneous recording of ventilation, respiratory effort; ECG or heart rate, and oxygen saturation, attended by a technologist
95822	Electroencephalogram (EEG); recording in coma or sleep only

Billing/Coding Information (RFA and Ablation)CPTCovered

32998	Ablation therapy for reduction or eradication of one or more pulmonary tumors; percutaneous, including imaging guidance when performed; radiofrequency
76940	Ultrasound guidance and monitoring of parenchymal tissue ablation
77013	CT guidance for and monitoring of parenchymal tissue ablation
77022	MRI guidance for and monitoring of parenchymal tissue ablation

Other CPT / Lab / Blood CodesCPT

86316	Immunoassay for tumor antigen; other antigen, quantitative
86945	Irradiation of blood product; each unit
99183	Physician attendance and supervision of hyperbaric oxygen therapy, per session

Provider Actions, Authorization & Documentation

Prior Authorization

Prior Authorization / Coverage Verification

Prior authorization is required for procedures and device services when indicated by individual policy sections; providers must verify benefits and obtain any required prior authorization prior to scheduling. Coverage and preauthorization are dependent upon the member’s individual benefit plan in effect at the time of service.

Prior authorization required where policy sections list it (e.g., bronchial valve procedures, diaphragmatic/phrenic nerve pacing, Inspire implantation, RFA, HBOT).
Inclusion of CPT/HCPCS codes in policy is informational and does not guarantee member coverage or provider reimbursement; verify member contract benefits.
Providers should contact Select Health Provider Relations (801-442-3692) or Member Customer Service (number on member ID card) for benefit questions.

Billing Rule

Definitions & Background

Asthma is a chronic inflammatory disorder characterized by airway hyperresponsiveness and airway smooth muscle hypertrophy. Bronchial thermoplasty is a minimally invasive bronchoscopic radiofrequency procedure performed in three outpatient treatments approximately three weeks apart that applies controlled radiofrequency energy to reduce airway smooth muscle mass; it is intended for select patients with severe persistent asthma who meet the policy's coverage criteria.

Revision History

2025-03-06criteria_revision

Modified overall Commercial Plan coverage criteria to align with current clinical guidelines and added requirements limiting RFA to no more than 3 tumors per lung, requiring tumors be amenable to complete ablation, and specifying a 12-month interval related requirement.

2024-07-07age_threshold_change

Lowered minimum commercial age for general Inspire UAS criteria from 22 to 18 years and added coverage criteria for adolescents with Down syndrome (ages 13–18).

2024-06-14

OpenPayer

Bronchial Thermoplasty for Asthma

Coverage Criteria

Coding and Billing

Provider Actions, Authorization & Documentation

Definitions & Background

Revision History