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ModifiedSelectHealthPolicy 379

Bronchial thermoplasty for asthma

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Coverage criteria and clinical background for bronchial thermoplasty (BT) in SelectHealth commercial, Medicare (when CMS has no criteria), and Community Care (Medicaid) plans; outlines when BT is covered vs investigational.

Policy Summary

PayerSelectHealth

PolicyBronchial thermoplasty for asthma

Policy CodePolicy 379

Change TypeMultiple substantive revisions to coverage criteria and prior‑auth/age thresholds

Effective DateAug 16, 2023

Last ReviewJun 19, 2025

Next Review Date

Key ActionObtain prior authorization and document failure of optimized controller therapy (6 months of inhaled LABA + inhaled corticosteroid) plus recent PFTs and other listed eligibility criteria before requesting bronchial thermoplasty.

SourceLink

POLICY UPDATE CHANGES

For Commercial Plan Policy, added new criterion #2 (immotile cilia syndrome) to list of conditions that would qualify for coverage of this therapy.

For Commercial Plan Policy, modified requirements in both criterion #A-5 and #B-6: 'Documentation which demonstrates CPAP failure (defined as AHI greater than 15 despite CPAP usage) or CPAP intolerance (defined as less than 4 hours per night, 5 nights per week ); or documentation supports non-compliance for at least 6 months.'

For Commercial Plan Policy, modified criterion #A2 to allow polysomnography or home sleep testing within 24 months of Inspire stimulator consult.

For Commercial Plan Policy, updated AHI range to 15 to 100 events per hour and BMI threshold to BMI < 40 kg/m2 in prior revisions.

For Commercial Plan Policy, overall coverage criteria were modified to align with current clinical guidelines and three additional requirements were added: no more than 3 tumors per lung should be ablated; tumors should be amenable to complete ablation; twelve months should elapse before a repeat ablation is considered.

For Commercial Plan Policy, added criterion #3 to section II as an additional qualifying factor: patient has evidence of Upper Airways Resistance Syndrome diagnosed by polysomnography (with at least 5 respiratory-related arousals per hour) with any of the comorbid conditions listed.

Changed minimum age requirement to qualify for a home sleep study in Section I, Criterion #A from 18 years to 15 years for Commercial Plan Policy.

Added sleep certified anesthesiologists (ABA certified) as eligible physicians evaluating these studies in Criterion #D for Commercial Plan Policy.

Modified wording of 'CompSA' to clarify this is 'complex sleep apnea' in section IV of criteria.

Updated confirmation requirements for complex sleep apnea/treatment-emergent sleep apnea including numeric thresholds for central events and proportion of central events.

For Commercial Plan Policy, modified requirements listed in criterion #2a-1: 'polysomnography is indicated in children with bronchopulmonary dysplasia only if there is clinical suspicion for an accompanying sleep-related breathing disorder.'

3outpatient procedures per BT treatment course

Must meet ALLCoverage requires meeting all listed criteria

StratX+Chartiscollateral ventilation assessment required

FDA PMA 2010Alair system approval referenced

AIR2Key evidence trial

Coverage Criteria

Commercial plan initial coverage

Covered when ALL of the following are met:

EPR3 severe persistent asthma: Patient has severe persistent asthma defined by Expert Panel Report 3 (EPR3) criteria (e.g., continual symptoms limiting physical activity; frequent nighttime symptoms defined as at least 4 of 7 nights weekly)EPR3

See policy references for full EPR3 criteria

Objective pulmonary function impairment: Abnormal pulmonary function tests performed within the last 6 months prior to the request demonstrating required deficits per policyPFTs within 6 months

Provide recent PFT results (FEV1 etc.)

Medication trial and adherence: Documented use of both inhaled long-acting bronchodilator agents (LABA) and inhaled corticosteroids for the 6 months immediately prior to BT request, with evidence of medication adherence (eg, pharmacy claims)6 months of LABA + inhaled corticosteroid

Medication adherence documentation required

Exacerbation history: One of the following must be present: required frequent or persistent systemic steroid boluses to treat exacerbations; OR experienced hospitalization or emergency department visit for asthma despite verified medication adherenceone of two events

Document steroid bursts or hospitalization/ER despite adherence

Evidence and background citations

Supporting evidence, regulatory and background citations relevant to the coverage criteria:

Clinical trials and systematic reviews: Key references include randomized controlled trials and systematic reviews of bronchial thermoplasty (eg, AIR, AIR2, RISA trials; CTAF and NICE assessments) documenting efficacy, safety, and long-term (up to 5 years) outcomes.

See bibliography (FDA PMA, CTAF, AIR2, meta-analyses) for full citations

Regulatory clearance: FDA premarket approval for the Alair Bronchial Thermoplasty System (Alair Catheter and Alair RF Controller) is cited as the regulatory basis for device use.

FDA PMA referenced

Evidence limitations: Evidence is mixed; methodological limitations and conflicting results (including safety signals and missing data in some RCTs) warrant restricting use to patients meeting the specified criteria.

AIR2 trial and subsequent reviews noted limitations

Lung volume reduction (severe emphysema)

Covered for adults when ALL of the following are met for lung volume reduction (one lobe only):

Emphysema confirmed and patient selection: Emphysema confirmed by CT scan; smoking cessation for at least 4 months prior to procedure; BMI < 35; clinically severe impairment after failed medical management and rehabilitation.smoking cessation >=4 months; BMI <35

Document CT and smoking history; conservative therapy must have failed

Physiologic inclusion thresholds: Pulmonary function and exercise thresholds: FEV1 15–45% predicted; TLC ≥100% predicted; RV >150% predicted (≥200% if homogeneous emphysema); six-minute walk distance 100–500 m (150–500 m if homogeneous emphysema).FEV1 15–45%; RV >150%

Provide PFTs and 6MWD within required timeframes

Collateral ventilation assessment: Target lobe demonstrates little or no collateral ventilation as determined by both StratX quantitative CT analysis and confirmation with Chartis physiologic measurement at bronchoscopy.

Prolonged air leak / bronchopleural fistula

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

Refractory prolonged air leak: Endobronchial valve (EBV) may be used to treat bronchopleural fistulas or prolonged air leaks that are refractory to other standard management approaches.refractory to standard management

IBV Valve System use limited per FDA HDE labeling (eg, 6 weeks) where applicable; document prior treatments and failure

Evidence-derived eligibility factors

Evidence-derived eligibility factors and trial enrollment elements that inform coverage decisions:

VENT trial eligibility example: VENT RCT eligibility included heterogeneous emphysema, FEV1 15–45% predicted, TLC >100% predicted, RV >150% predicted, and post-rehabilitation 6-minute walk distance ≥140 m — criteria used to inform patient selection in policy.as stated in trial

VENT trial enrollment parameters informed policy thresholds

Limitations to consider: RCTs and case series had missing data and adverse events; results showed modest absolute changes and variable clinical significance, emphasizing careful candidate selection per policy criteria.

Document risk/benefit discussion in medical record

Covered indications and neuromuscular-specific requirements

SelectHealth covers HFCWC devices for patients with the following (Commercial Plan):

Primary eligible conditions: Cystic fibrosis OR Immotile cilia syndrome OR Bronchiectasis OR Neuromuscular disorders when additional neuromuscular-specific criteria are met.

HFCWC not covered for COPD or other non-listed conditions

Neuromuscular disorder additional criteria: For neuromuscular disorders, ALL of the following: a) Well-documented failure of standard treatments to mobilize retained secretions including chest physiotherapy at least twice daily; b) a pattern of hospitalizations or significantly deteriorating clinical condition; c) adequate cough to remove mobilized secretions or use of cough-assist device; AND pulmonary evaluation/consultation; AND rental trial prior to purchase (plan-dependent).failed chest PT >= twice daily

Documentation of failed standard therapy and pulmonary consult required

Covered Indications

HBO2/HBOT is covered for specified indications when condition-specific criteria are met; visit limits apply and some indications require prior/concurrent therapies or time windows:

Acute idiopathic sudden sensorineural hearing loss (ISSHL): Onset <30 days; formal audiometry demonstrating >30 dB loss affecting >3 consecutive frequencies; concurrent systemic or injected steroids per ENT; initial 10 treatments authorized, additional 10 treatments approvable if >20 dB improvement or improved voice discrimination after initial course.10 initial treatments; additional 10 with documented response

ENT involvement and audiometry documentation required

Carbon monoxide intoxication (acute symptomatic): Exposure confirmed; carboxyhemoglobin (CoHb) >10% in adults (or >5% in children/nonsmokers) supports exposure; treatment must be started less than 24 hours from poisoning to be approved.treatment started <24 hours; CoHb >10% (adults)

Document exposure confirmation and timing

Central retinal artery occlusion:

Covered Indications / Criteria Examples

Examples of covered HBOT indications with required documentation and limits (extracted examples):

CO poisoning (acute symptomatic): Exposure to carbon monoxide confirmed with persistent symptoms; CoHb >10% (adults) supports diagnosis; treatment approved only if initiated <24 hours from exposure; other confirmation (gas company/fire dept.) acceptable.time <24 hours; CoHb >10% adults

Document exposure confirmation and treatment timing

ISSHL use considerations: HBOT may improve hearing in acute idiopathic sudden sensorineural hearing loss when used adjunctively with systemic steroids; evidence limited and benefit greater in younger patients and those with severe loss; initial treatment course and response criteria apply.age <50 may favor benefit; initial 10 treatments

ENT consultation and audiometry required

Use as last resort: HBOT is generally reserved as a last-resort therapy when other options are exhausted; document prior therapies and rationale for HBOT given risks and variable outcomes.

Inspire implantation coverage criteria

Covered when ALL of the following are met:

Adult Inspire implantation criteria: 1) Age ≥18 years; 2) Moderate-to-severe OSA with AHI 15–100 events/hour documented by polysomnography or home sleep testing within 24 months; 3) Central and mixed apneas <25% of AHI; 4) Recommendation by ENT and sleep specialist; 5) Documentation of CPAP failure (AHI >15 despite CPAP) or CPAP intolerance (defined as <4 hours/night on ≥5 nights/week) or documented non-compliance ≥6 months; 6) No anatomic findings that would compromise device performance; 7) BMI <40 kg/m2; 8) Oral appliance inadequate or inappropriate; 9) Implantation by an ENT.AHI 15–100; BMI <40; CPAP usage <4 hrs/night x5 nights/week or AHI>15 on CPAP; non-compliance >=6 months

Documentation from ENT and sleep specialist required

Adolescent Down syndrome Inspire criteria: For adolescents 13–18 with Down syndrome: AHI ≥10 and ≤50; similar anatomic and CPAP trial/intolerance documentation required; recommendation by ENT and sleep specialist; implant by ENT.AHI 10–50; age 13–18

Refer to policy for recognized sleep specialists

Inspire Upper Airway Stimulation - Covered with criteria

Covered when ALL of the following are met (per commercial policy revisions):

Inspire UAS commercial eligibility summary: Candidates must have moderate-to-severe OSA with AHI 15–100 events/hr documented by PSG or home sleep testing within 24 months; meet BMI threshold (BMI <40 kg/m2); have documentation of CPAP failure (AHI >15 on CPAP) or CPAP intolerance (defined as <4 hours/night on ≥5 nights/week), or documented non‑compliance for at least 6 months; central/mixed apneas <25% of events; recommendation by ENT and sleep specialist; implant performed by ENT. Evidence graded low (Grade 2B) and clinical outcome data limited.AHI 15–100; BMI <40; CPAP usage criteria

Revision history documents updates to AHI and BMI thresholds and operationalized CPAP definitions

Mechanical Insufflation-Exsufflation (CoughAssist) - Covered with criteria

Covered when ALL of the following are met:

MI-E coverage for neuromuscular/chest-wall impairment: Patient has ventilatory insufficiency or difficulty clearing secretions due to a qualifying neuromuscular disorder (eg, muscular dystrophy, amyotrophic lateral sclerosis, spinal muscular atrophy, poliomyelitis), spinal cord injury, myasthenia gravis, or significant impairment of chest wall/diaphragmatic movement; device is used to improve cough and airway clearance with documented clinical need and pulmonary evaluation/consultation.clinical diagnosis of qualifying neuromuscular/chest wall impairment

Contraindications (history of bullous emphysema, lung cysts, susceptibility to pneumothorax/pneumomediastinum, recent barotrauma) prohibit coverage

Covered indications (summary)

Covered when conditions outlined in the policy are met

Policy-level coverage summary: Coverage is provided for the conditions and criteria described in the policy; evidence supporting MI-E is mainly case series showing improved intermediate outcomes (eg, peak cough expiratory flow).

Refer to full policy for detailed medical necessity documentation requirements

RFA - Primary NSCLC

Covered when ALL of the following are met:

RFA for primary peripheral NSCLC ≤3 cm: 1) Isolated peripheral non–small-cell lung cancer lesion ≤3 cm; 2) Surgical resection or radiotherapy with curative intent would be appropriate but the patient is unfit due to medical comorbidity; 3) Tumor located ≥1 cm from trachea, main bronchi, esophagus, aorta and branches, pulmonary artery, and heart.size ≤3 cm; distance ≥1 cm

Procedure billed with CPT 32998 and appropriate imaging guidance codes

RFA for metastatic nonpulmonary tumors to lung ≤3 cm: 1) Necessary to preserve lung function because surgery or radiotherapy would substantially worsen pulmonary status OR patient not surgical candidate with no extrapulmonary metastases; 2) Tumors ≤3 cm; 3) Tumor located ≥1 cm from major central structures; 4) No more than 3 tumors per lung; 5) Tumors amenable to complete ablation; 6) At least 12 months must elapse before repeat ablation is considered.size ≤3 cm; ≤3 tumors per lung; 12 months between repeat ablations

Document imaging, tumor counts, and prior treatments; CPT 32998 applies

RFA - Metastatic to Lung

Covered when ALL of the following are met:

RFA metastatic to lung criteria: See criteria for metastatic tumors to lung: preservation of lung function, tumor size ≤3 cm, location ≥1 cm from central structures, no more than 3 tumors per lung, amenable to complete ablation, and 12‑month interval before repeat ablation.size ≤3 cm; ≤3 tumors/lung; 12 months before repeat

Aligns with recent revision adding explicit limits and guidance

Initial and repeat ablation coverage

Covered when ALL of the following are met (per revised commercial plan criteria):

Initial and repeat ablation coverage prerequisites: 1) Indication consistent with policy for percutaneous RFA of primary or metastatic pulmonary tumors; 2) No more than 3 tumors per lung to be ablated; 3) Tumors should be amenable to complete ablation; 4) If prior ablation performed, at least 12 months must elapse before repeat ablation; 5) Procedure billed with appropriate CPT codes (eg, 32998) and imaging guidance as applicable.no more than 3 tumors/lung; 12 months between repeat ablation

Document prior ablations, imaging guidance, and tumor amenability

Home sleep study (Type III/II) criteria

Covered when ALL of the following are met

Home sleep study (Type III/II) eligibility: Member is at least 15 years of age; member does not have medical conditions that increase the risk of central sleep apnea (eg, heart failure, neuromuscular disease, moderate-to-severe COPD, history of stroke, chronic opioid use); member does not have seizure disorder, dementia, developmental delay, or morbid obesity; and the physician performing the test is board-certified/ABSM diplomate or equivalent per policy.age ≥15; exclusions as listed

Home testing intended for diagnosis of OSA in high pretest probability patients

Continued CPAP rental/purchase

Covered when ALL of the following are met

Continued CPAP rental/purchase: Diagnosis of OSA confirmed by PSG or home sleep testing and presence of qualifying symptoms/comorbidities (eg, excessive daytime sleepiness, impaired cognition, mood disorder, insomnia, hypertension, ischemic heart disease, history of stroke) OR evidence of Upper Airway Resistance Syndrome with comorbidity; AND demonstrated adherence defined as ≥4 hours/night for 70% of nights over a consecutive 30-day period.>=4 hours/night for 70% of nights over 30 days

Initial minimum 3-month rental required prior to purchase or continued rental; adherence must be documented via device download or inspection

Continued BiPAP rental/purchase

Covered when ALL of the following are met

Continued BiPAP rental/purchase: Diagnosis of OSA confirmed by PSG with qualifying symptoms/comorbidities; demonstrated adherence (≥4 hours/night for 70% of nights over 30 consecutive days); AND documentation that CPAP (HCPCS E0601) was tried and proven ineffective after troubleshooting (appropriate interface fit, pressure adjustments) prior to switching to BiPAP.Adherence >=4 hours/night for 70% of nights; initial 7‑month rental

Initial minimum 7‑month rental required prior to purchase or continued rental; document CPAP troubleshooting

Continued ASV rental/purchase

Covered when BOTH of the following are met

Continued ASV rental/purchase: A confirmed diagnosis of central sleep apnea or complex/treatment‑emergent sleep apnea by PSG with required central-event thresholds and clinical features; AND demonstrated adherence (≥4 hours/night for 70% of nights over a consecutive 30‑day period).Adherence >=4 hours/night for 70% of nights

Initial minimum 3‑month rental required prior to purchase or continued rental

Diagnostic and Titration Criteria

Covered when diagnostic thresholds or documentation requirements are met

Positive OSA test criteria: Either AHI/RDI ≥15 events/hour with a minimum of 30 events OR AHI/RDI 5–14 events/hour with a minimum of 10 events plus documented qualifying symptoms (excessive daytime sleepiness, impaired cognition, mood disorder, insomnia) or specified comorbidities (hypertension, ischemic heart disease, stroke).See AHI/RDI thresholds

If based on <2 hours recorded sleep, event counts must meet 2‑hour equivalent

CPAP titration via split-night: CPAP titration may be performed as split-night; CPAP titration portion must be >3 hours and polysomnography must document elimination or near-elimination of respiratory events during REM and NREM sleep.CPAP titration >3 hours

Split-night is acceptable alternative to two-night approach

Home sleep testing physician/service requirements: Home sleep testing services (G0398, G0399, G0400) are covered when reasonable and necessary, performed in patients with high pretest probability of moderate‑to‑severe OSA, and provided by physicians with required board certification/credentials.

Covered Indications (Commercial/CHIP)

Covered when ALL of the following are met: the study will alter the patient's treatment plan and the patient meets one of the listed clinical indications.

General requirement

Clinical indications (one required): One of the following must be present: obstructive sleep apnea syndrome (differentiation from primary snoring; evaluation for disturbed sleep, excessive daytime sleepiness, cor pulmonale, failure to thrive, or polycythemia; postoperative monitoring with risk factors; laryngomalacia with failure to thrive or cor pulmonale; sickle cell disease with nocturnal events and positive oximetry; persistent post-op symptoms >4 weeks; titration of CPAP/BiPAP); bronchopulmonary dysplasia with clinical suspicion for sleep-related breathing disorder; cystic fibrosis with nocturnal oximetry showing concerns; neuromuscular disease with chronic impairment; or alveolar hypoventilation with hypercapnia and hypoxia.varies by pediatric indication
See policy sections for age- and condition‑specific criteria

Use of services or devices outside the specific clinical criteria listed in this policy is considered experimental/investigational and may be denied. SelectHealth applies coverage only when the documented clinical criteria are all met for the indication in question; requests that fall outside those criteria should be treated as requiring additional clinical justification and are subject to utilization review and potential denial.

Coverage and benefit determinations depend on the member's individual benefit plan and contract in effect at the time of service. Inclusion or exclusion of a procedure, diagnosis, or device code in this policy does not, by itself, guarantee coverage or payment. Providers and members should verify plan-specific benefits and prior authorization requirements before scheduling services.

Certain devices and indications listed in the policy are explicitly identified as investigational/experimental and are not covered. The policy notes investigational status adjacent to specific HCPCS/CPT groupings and describes limited or insufficient data for some devices and uses, which may preclude coverage for those items or indications.

The available evidence for use of endobronchial valves (EBV) to treat persistent air leaks is limited to small, uncontrolled case series. Because of small sample sizes, heterogeneity, and lack of comparative data, the evidence is insufficient to determine a clear risk–benefit profile and EBV use for persistent air leaks may be excluded or restricted.

High-frequency chest wall compression (HFCWC) devices and endobronchial valves are not covered for a range of other medical conditions where effectiveness has not been established. Examples include chronic obstructive pulmonary disease (COPD) and other non‑established indications (e.g., alpha‑1 antitrypsin deficiency, childhood atelectasis, cerebral palsy, scoliosis), where the plan considers such uses experimental/investigational and not covered.

SelectHealth lists numerous uses of hyperbaric oxygen therapy (HBOT/HBO2) that are considered investigational and are not covered. The policy explicitly excludes conditions such as anemia, arthritic diseases, brain or spinal cord injury, multiple sclerosis, migraine, pulmonary emphysema, Raynaud's phenomenon, and many others; see the policy exclusion list for the full set of non‑covered indications.

The disposable topical hyperbaric oxygen chamber (HCPCS code A4575) is listed as not covered and may be denied when billed. Providers should not use A4575 for members expecting coverage under this policy.

Revision history entries document added exclusions to HBOT coverage; for example, arterial/ischemic leg ulcers and related peripheral vascular/neuropathy exclusions were added to the list of non‑covered conditions in a policy update and should be checked in the current exclusion list when evaluating claims.

Mechanical insufflation‑exsufflation (MI‑E, CoughAssist) is covered only when the patient meets neuromuscular or significant chest‑wall/diaphragmatic impairment criteria. MI‑E is not covered for patients who do not meet those criteria and is contraindicated (and therefore not covered) for individuals with a history of bullous emphysema, lung cysts, susceptibility to pneumothorax or pneumomediastinum, or recent barotrauma.

Within the portions of the document excerpted, no specific CPT procedure codes were identified for certain items; where no CPT guidance is provided in the policy text, providers should rely on the documented HCPCS/CPT lists elsewhere in the policy and verify coding with Provider Relations if uncertain.

The MESOMARK (soluble mesothelin‑related peptide) test is labeled Not covered: Investigational/Experimental/Unproven for the indication discussed. CPT billing codes referenced in the policy for MESOMARK testing are provided for informational purposes but do not imply coverage.

Evidence supporting radiofrequency ablation (RFA) as a primary management strategy for pulmonary tumors demonstrates inconsistent effects on overall survival across studies. While some series report local control and intermediate outcomes, many studies do not identify a clear survival benefit when RFA is used as primary therapy; this uncertainty factors into coverage determinations for RFA and supports limiting coverage to patients meeting specified clinical criteria.

Home sleep studies (Type III/II) are not covered for patients with listed high‑risk conditions or comorbidities. Examples include heart failure, neuromuscular disease, moderate‑to‑severe COPD, history of stroke, chronic opioid use, seizure disorder, dementia, developmental delay, and morbid obesity. Home testing is intended only for diagnosis of obstructive sleep apnea (OSA) in appropriately selected patients and not for other sleep disorders or asymptomatic screening.

The policy states home sleep testing is not intended for persons with significant comorbidities (moderate‑to‑severe pulmonary disease, neuromuscular disease, or congestive heart failure) and should not be used to diagnose disorders other than OSA; such cases require in‑laboratory polysomnography.

Reminder: inclusion or exclusion of codes in this policy does not itself constitute member coverage or guarantee payment. Coverage and benefits are determined by the member's individual benefit plan and contract in effect at the time of service; providers should verify eligibility, benefits, and prior authorization requirements with the member's plan.

Bronchial thermoplasty (BT) evidence is mixed with methodological limitations and variable results across trials. Systematic reviews and available randomized trials (notably AIR2) provide some support for efficacy in selected patients, but methodological concerns, inconsistent findings, and limited long‑term data lead SelectHealth to consider BT outside defined criteria as investigational. Where BT criteria are met, the policy applies coverage cautiously and requires documentation of prior optimized medical therapy.

The policy identifies certain implantable neurostimulator HCPCS codes as investigational/unproven for the stated indications; these codes and related device uses may be excluded from coverage unless specific criteria or FDA approvals are documented and applicable.

For advanced emphysema, evidence for bronchoscopic endobronchial valves is limited to case series and a single unblinded randomized trial; the available data do not provide consistent or robust evidence of net health benefit. As a result, EBV placement is restricted to the criteria listed in the policy (e.g., treatment limited to one lobe, device FDA‑approved and used per labeling) and other uses are considered investigational.

High-frequency chest wall compression (HFCWC) vest therapy for COPD and other non‑established indications is considered experimental/investigational and is not covered. Evidence in neuromuscular disease or cystic fibrosis is limited but may support coverage for those specific indications when policy criteria are met.

SelectHealth lists numerous HBOT uses as investigational and not covered. In addition, HBOT has limited or equivocal evidence for some chronic conditions (for example, chronic idiopathic sudden sensorineural hearing loss and tinnitus) and is reserved as a last‑resort therapy in covered indications, with documentation of prior standard therapies required.

For idiopathic sudden sensorineural hearing loss (ISSHL), randomized and systematic reviews report some benefit for acute presentations when HBOT is used adjunctively with systemic steroids, but the evidence quality is limited and clinical significance uncertain. The policy therefore limits HBOT use to indications meeting the listed criteria and does not support HBOT for chronic ISSHL or tinnitus.

Evidence for hypoglossal nerve stimulation (Inspire and similar implantable hypoglossal neurostimulation systems) is graded as low (Grade 2B) in the policy. Although trials report improvements in AHI, ODI, and sleep quality measures, the evidence volume is limited and long‑term, large‑scale clinical outcome benefits remain unproven.

Hypoglossal neurostimulation is described as promising but unproven given the limited number of patients studied and low overall evidence level; coverage is therefore restricted to the specific eligibility criteria and documentation requirements detailed in the policy.

Portions of the policy are not fully specified in the excerpt; when clinical detail is absent, the policy reiterates that benefit determination rests with the member's plan and providers should contact SelectHealth Provider Relations or Customer Service for clarification of coverage for individual cases.

Reiterating earlier statements, the MESOMARK serum SMRP measurement is considered investigational/unproven for the indication discussed and is labeled not covered; billing codes shown in the policy are informational only.

Multiple studies of RFA report intermediate outcomes and variable local control but inconsistent evidence for an overall survival benefit when RFA is used as primary management. This inconsistency informs the policy stance and supports limiting RFA coverage to patients who meet specified clinical criteria.

For Medicare members, coverage is determined by the Centers for Medicare & Medicaid Services (CMS). If CMS has not issued a determination and InterQual criteria are unavailable, the SelectHealth commercial policy applies; providers should check CMS policy for Medicare members before applying commercial criteria.

Home sleep studies are appropriate only for diagnosis of OSA in selected patients and are not appropriate for disorders other than OSA or for asymptomatic screening. Other diagnostic techniques (videotaping, nocturnal oximetry, daytime nap studies) have high false‑negative rates and negative results should prompt formal polysomnography when clinical suspicion remains.

The policy cautions that other simpler diagnostic techniques (videotaping, nocturnal oximetry, daytime nap studies) have a high rate of false‑negative results and are insufficient to rule out OSA; negative findings on these tests should lead to formal polysomnography where clinically indicated.

Coding

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

HCPCSHCPCS

No codes listed

CPT CODES (listed in this section of the document)CPT

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

HCPCS CODES (listed in this section of the document)HCPCS

L8680	Implantable neurostimulator electrode, each
L8682	Implantable neurostimulator radiofrequency receiver
L8683	Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
L8685	Implantable neurostimulator pulse generator, single array, rechargeable, includes Extension
L8686	Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
L8688	Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension
L8689	External recharging system for battery (internal) for use with implantable neurostimulator

Not covered / investigational codes (as listed here)mixedNot Covered

G12.21

Not covered: Investigational/Experimental/Unproven for this indication

HCPCS codes listedHCPCS

L8680	Implantable neurostimulator electrode, each
L8682	Implantable neurostimulator radiofrequency receiver
L8683	Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
L8685	Implantable neurostimulator pulse generator, single array, rechargeable, includes Extension
L8686	Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
L8688	Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension
L8689	External recharging system for battery (internal) for use with implantable neurostimulator

Not covered / investigational mentionICD-10Not Covered

G12.21

Not covered: Investigational/Experimental/Unproven for this indication (as listed)

CPT CODESCPT

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])

HCPCS CODESHCPCS

No codes listed

CPT CodesCPT

No codes listed

HCPCS CodesHCPCSCovered

A7025	High frequency chest wall oscillation system vest, replacement for use with patient owned equipment, each
A7026	High frequency chest wall oscillation system hose, replacement for use with patient owned equipment
E0480	Percussor, electric or pneumatic, home model
E0483	High frequency chest wall oscillation air-pulse generator system (includes hoses and vest), each

Covered CPT Codes (HBOT related)CPTCovered

99183

Physician attendance and supervision of hyperbaric oxygen therapy, per session

Covered HCPCS Codes (HBOT related)HCPCSCovered

G0277

Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

Not coveredHCPCSNot Covered

A4575

Topical hyperbaric oxygen chamber, disposable

Covered CPT Codes (Inspire hypoglossal neurostimulation)CPTCovered

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

Additional Covered CPT Codes (hypoglossal neurostimulation)CPTCovered

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

Additional CPT CodesCPTCovered

64584	Removal of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array
64568	Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator
64569	Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator
64570	Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator
64999	Unlisted procedure, nervous system (When specified as implantation of a hypoglossal nerve stimulator)

HCPCS Codes (Hypoglossal neurostimulation devices)HCPCS

L8679	Implantable neurostimulator, pulse generator, any type
L8680	Implantable neurostimulator electrode, each
L8686	Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension

CPT CODESCPT

No specific codes identified

Policy states no specific CPT codes identified

HCPCS CODESHCPCSCovered

A7020	Interface for cough stimulating device, includes all components, replacement only
E0482	Cough stimulating device, alternating positive and negative airway pressure

CPT CODES (MESOMARK billing)CPT

86316	Immunoassay for tumor antigen, other antigen, quantitative (e.g., CA 50, 72-4, 549), each
86945	Irradiation of blood product, each unit

HCPCS CodesHCPCS

No codes listed

Covered CPT CodesCPTCovered

32998	Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; radiofrequency
76940	Ultrasound guidance for, and monitoring of, parenchymal tissue ablation
77013	Computed tomography guidance for, and monitoring of, parenchymal tissue ablation
77022	Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation

HCPCS CodesHCPCS

No codes listed

Referenced HCPCS codeHCPCS

E0601

CPAP device

Covered CPT Codes (home sleep testing physician service codes)CPTCovered

94660	Continuous positive airway pressure ventilation (CPAP), initiation and management.
95782	Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters, attended by a technologist.
95783	Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters, with initiation of CPAP or bilevel ventilation, attended by a technologist.
95800	Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis, and sleep time.
95801	Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis.
95805	Multiple sleep latency or maintenance of wakefulness testing.
95806	Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow, and respiratory effort.
95807	Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist.
95808	Polysomnography; any age, sleep staging with 1-3 additional parameters, attended by a technologist.
95810	Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters, attended by a technologist.

1–10 of 11

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Covered HCPCS Codes (home sleep testing)HCPCSCovered

E0601	Continuous positive airway pressure (CPAP) device.
E0470	Respiratory assist device, bi-level pressure capability, without backup rate feature.
E0471	Respiratory assist device, bi-level pressure capability, with backup rate feature, noninvasive.
E0472	Respiratory assist device, bi-level pressure capability, with backup rate feature, invasive.
G0398	Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels.
G0399	Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels.
G0400	Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels.

AccessoriesHCPCSCovered

A4604	Tubing with integrated heating element for use with positive airway pressure device.
A7027	Combination oral/nasal mask, used with CPAP device.
A7028	Oral cushion for combination oral/nasal mask, replacement only.
A7029	Nasal pillows for combination oral/nasal mask, replacement only.
A7030	Full face mask used with positive airway pressure device.
A7031	Face mask interface, replacement for full face mask.
A7032	Cushion for use on nasal mask interface, replacement only.
A7033	Pillow for use on nasal cannula type interface, replacement only.
A7034	Nasal interface used with positive airway pressure device.
A7035	Headgear used with positive airway pressure device.

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Covered CPT Codes (pediatric sleep studies)CPTCovered

95782	Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist.
95783	Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist.
95805	Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness.
95807	Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist.
95808	Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist.
95810	Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist.
95811	Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist.
95822	Electroencephalogram (EEG); recording in coma or sleep only

HCPCS CodesHCPCS

No codes listed

Pulmonary function test recency — performed within last 6 months prior to request

RequirementPulmonary function tests must be abnormal and performed within the last 6 months prior to the request

Provider Actions, Authorization & Documentation

Prior Authorization

Prior authorization required; coverage with criteria

Prior authorization is required; coverage is allowed only when all specified clinical criteria are met (for example, severe persistent asthma per EPR3, recent abnormal PFTs, documented 6‑month trial of inhaled LABA + inhaled corticosteroid, and qualifying exacerbation history). Submit prior authorization with complete clinical documentation demonstrating all required criteria are met.

Prior Authorization

Check member benefits and prior auth

Verify member benefits and prior authorization requirements before ordering services; benefits and coverage are determined by the member's individual benefit plan and FDA PMA or regulatory status may be referenced for devices (e.g., Alair PMA).

Prior Authorization

Prior authorization and criteria

Background

Asthma is a chronic inflammatory disorder of the airways managed with controller medications and bronchodilators. Bronchial thermoplasty (BT) is a bronchoscopic procedure using controlled radiofrequency energy applied over three outpatient treatments to reduce airway smooth muscle and improve control in selected patients with severe persistent asthma. BT is intended as an adjunct to, not a replacement for, maintenance pharmacotherapy and requires documentation of prior optimized medical therapy.

Definitions

Bronchial thermoplasty (BT) definition

DefinitionBronchial thermoplasty (BT) is a bronchoscopic procedure that applies controlled radiofrequency energy to airways to heat and reduce airway smooth muscle mass

CourseTypically performed in three outpatient procedures approximately three weeks apart

GoalIntended to complement maintenance medications to improve asthma control in severe persistent asthma

Severe persistent asthma (EPR3) definition

Definition sourceSevere persistent asthma defined per Expert Panel Report 3 (EPR3) criteria

Example featuresContinual symptoms limiting physical activity; frequent night-time symptoms (at least 4 of 7 nights weekly)

Revision History

2025-10-06revisedLatest

Modified pediatric polysomnography indication: polysomnography indicated in children with bronchopulmonary dysplasia only if there is clinical suspicion for an accompanying sleep-related breathing disorder.

2025-06-23revised

Clarified CPAP failure/intolerance and non-compliance timeframe in Inspire criteria: documentation must demonstrate CPAP failure (AHI >15 on CPAP) or CPAP intolerance (<4 hours/night on ≥5 nights/week) or non-compliance for at least 6 months.

2025-03-06

Policy Summary

PayerSelectHealth

PolicyBronchial thermoplasty for asthma

Policy CodePolicy 379

Change TypeMultiple substantive revisions to coverage criteria and prior‑auth/age thresholds

Effective DateAug 16, 2023

Last ReviewJun 19, 2025

Next Review Date

SourceLink

On This Page

StratX + Chartis confirmation

Both assessments required for target selection

Device and labeling compliance: Device(s) used must be FDA-approved and implanted/used according to FDA labeling; coverage is limited to treatment of one lobe only.one lobe only

Document device model and FDA approval

Diagnosis within ≤24 hours; prescribed 14 treatments (twice daily for 1 week) of 90 minutes each per policy.

condition ≤24 hours; 14 treatments specified

MD review and timing critical

Chronic diabetic lower extremity wounds: Diabetic patient with Wagner grade III or higher lower extremity wound who has failed an adequate 30-day course of standard wound therapy (vascular assessment, nutrition/glucose optimization, debridement, moist dressings, off‑loading, infection control); initial 20 treatments authorized; further increments require MD review.Wagner grade III+ and 30 days failed standard care

Document standard wound care trial

Other covered acute/refractory conditions: Selected conditions (decompression illness/gas embolism, mucormycosis, osteomyelitis refractory to conventional care, osteoradionecrosis, compromised grafts/flaps, necrotizing soft tissue infections, traumatic peripheral ischemia) covered with condition-specific visit limits and MD review as required.varies by condition

See policy for condition-specific visit counts

document prior therapies

MD review required for extended courses

high pretest probability

Home testing not intended for patients with specified comorbidities

PurposeDemonstrate objective impairment (FEV1, TLC, RV as applicable) to meet procedure criteria

DocumentationProvide PFT report showing dates and numeric values within 6-month window

Six-minute walk distance — 100-500 m (150-500 m if homogeneous emphysema)

Six-minute walk distance (heterogeneous emphysema)100–500 meters

Six-minute walk distance (homogeneous emphysema)150–500 meters

Trial eligibility noteUsed as an objective functional measure in pre-procedure assessment (VENT trial eligibility reflected)

FEV1 eligibility — 15-45% predicted

FEV1 range15–45% of predicted

ContextEligibility threshold used in VENT trial and required for EBV lung volume reduction assessment

DocumentationReport FEV1 % predicted from recent PFT within 6 months

TLC threshold — >= 100% predicted

TLC threshold>= 100% predicted

RolePart of physiologic eligibility for EBV lung volume reduction

Source exampleVENT trial required TLC >100% predicted

RV threshold — >150% predicted (>=200% if homogeneous emphysema)

Residual volume (RV)> 150% predicted

RV if homogeneous emphysema>= 200% predicted

SignificanceElevated RV indicates air trapping/hyperinflation used for EBV candidacy

BMI threshold for EBV — < 35

BMI threshold for EBV candidatesBMI < 35

DocumentationInclude BMI in pre-procedure clinical documentation

ContextRequirement for EBV lung volume reduction coverage (one lobe only)

Chest physiotherapy frequency (failed therapy) — at least twice daily

Failed chest physiotherapy frequencyAt least twice daily

ApplicationDefines failed conservative therapy criterion for HFCWC coverage in neuromuscular disorders

DocumentationDocument prior chest PT attempts at specified frequency

Standard wound therapy duration prior to HBO2 — 30 days

Standard wound therapy duration before HBOT30 days of adequate standard wound therapy

ComponentsIncludes vascular assessment, nutrition/glucose optimization, debridement, moist dressings, off‑loading, infection treatment

ConsequenceHBOT covered for chronic diabetic wounds only after documented 30-day failure

CO poisoning treatment window — < 24 hours

Treatment initiation window for CO poisoningTreatment approved only if started less than 24 hours from poisoning

RationaleCoHb levels degrade with time and oxygen therapy; prompt treatment required for efficacy

DocumentationConfirm exposure and time treatment started relative to exposure

COHb level for adults supporting exposure — > 10%

Adult CoHb supportive level> 10% (supports CO exposure)

NotesLevels should be assessed as soon as possible after exposure; levels degrade with time and oxygen therapy

DocumentationReport measured CoHb when available to support diagnosis

COHb level for children or nonsmokers — > 5%

Children or nonsmokers CoHb supportive level> 5% (may support exposure)

ContextLower threshold used because baseline carboxyhemoglobin may be lower in nonsmokers/children

TimingObtain sample promptly; levels decline with time and oxygen treatment

AHI — Adults 15-100 events/hr; Adolescents with Down syndrome >=10 and <=50

AHI — adults15 to 100 events per hour

AHI — adolescents with Down syndrome>= 10 and <= 50 events per hour

Documentation timeframePolysomnography or home sleep testing within 24 months of consult

BMI limit for Inspire — < 40 kg/m2

BMI limit for Inspire candidatesBMI < 40 kg/m2

ContextAligned with FDA‑approved indications and recent policy revisions

DocumentationInclude BMI in required pre-implant documentation

AHI numeric range (revision-aligned) — 15 to 100 events per hour

AHI numeric eligibility range15 to 100 events per hour

Acceptable testsPolysomnography or home sleep testing within 24 months

Revision noteRange updated in policy revisions to align with FDA indication

BMI (revision-aligned) — BMI < 40 kg/m2

BMI criterion (revision-aligned)BMI < 40 kg/m2

UseEligibility requirement for Inspire hypoglossal neurostimulator

DocumentReport BMI measured prior to consult

Tumor size limit for RFA — no more than 3 cm

Maximum tumor size for RFANo more than 3 cm

ContextApplies to primary and metastatic pulmonary tumor ablation eligibility

DocumentationImaging report confirming lesion size required

Maximum tumors per lung for ablation — no more than 3 tumors per lung

Maximum tumors per lungNo more than 3 tumors per lung

Policy revisionAdded as an explicit coverage requirement in recent revisions

ImplicationAblation of >3 tumors per lung may trigger denial

Interval before repeat ablation — 12 months

Interval before repeat ablation12 months must elapse before repeat ablation is considered

RationaleEnsures alignment with clinical guidelines and avoids premature repeat procedures

DocumentationPrior ablation date and clinical justification required for consideration

Adherence threshold for continued device coverage — >= 4 hours/night for 70% of nights over 30 consecutive days

Adherence threshold for continued device coverage>= 4 hours/night for 70% of nights over a consecutive 30-day period

VerificationAdherence must be documented via direct device download or visual inspection of usage data

Applies toContinued CPAP/BiPAP/ASV rental or purchase coverage

AHI/RDI thresholds for positive OSA test — >=15 with min 30 events OR 5-14 with min10 events + symptoms/comorbidities

Positive OSA test — AHI/RDI >=15AHI or RDI >= 15 events/hour with a minimum of 30 events

Positive OSA test — AHI 5–14 plus symptomsAHI or RDI 5–14 events/hour with minimum 10 events plus documented qualifying symptoms or comorbidities

Event minimumsMinimum event counts required (30 or 10) apply when determining positive test

CPAP titration duration — > 3 hours

CPAP titration duration requirementCPAP titration must be carried out for more than 3 hours

ApplicationApplies to split-night CPAP titration studies prior to device initiation

DocumentationPolysomnography must document elimination or near-elimination of respiratory events during REM and NREM when titration performed

AHI/RDI calculation when <2 hours recorded — total recorded events must be at least the number that would have been required in a 2-hour period

AHI/RDI calculation when <2 hours recordedTotal recorded events must be at least the number that would have been required in a 2‑hour period

PurposeEnsures valid AHI/RDI calculation when recording time is short

DocumentationReport total event count and recording duration for truncated studies

Obstructive events per hour threshold — > 10 obstructive events per hour

Obstructive events per hour threshold (pediatric care)> 10 obstructive events per hour

ContextOne of criteria for intensive postoperative monitoring after adenotonsillectomy and other pediatric indications

DocumentationProvide PSG report showing event rate and associated SaO2 if applicable

Oxygen saturation threshold — SaO2 < 70%

Oxygen saturation threshold (pediatric)SaO2 < 70%

ApplicationCriterion for intensive postoperative monitoring and other pediatric PSG indications

DocumentationInclude nadir SaO2 from monitoring in PSG report

Prior authorization is required per plan rules and coverage is applied only when the full Commercial plan clinical criteria are documented for the requested service.

Prior Authorization

Prior authorization for bronchial valve procedures

Prior authorization is expected for bronchoscopic valve procedures; include documentation supporting indication (e.g., emphysema with CT confirmation, failed medical management) and evidence of target‑lobe little‑to‑no collateral ventilation.

Include CPT codes for valve insertion/removal (31647, 31648, 31649, 31651) on claims
Provide CT confirmation and StratX/Chartis assessment of collateral ventilation

Prior Authorization

Prior authorization and rental trial

Prior authorization or a rental trial may be required prior to purchase of durable equipment; confirm member plan rules as rental‑trial requirements vary by plan.

Document rental trial when applicable prior to purchase as required by the member's benefit plan

Prior Authorization

Prior authorization required for HBO2/HBOT

Prior authorization/utilization review is required for hyperbaric oxygen therapy (HBO2/HBOT) and for requests exceeding initial visit limits; requests for additional visits beyond the initial course require MD review with documentation of substantial improvement.

Submit prior authorization for HBOT requests that exceed listed initial visit counts
Additional courses require MD review and documentation of clinical improvement

Billing Rule

Authorization for HBOT sessions

Prior authorization is required for HBOT sessions billed with CPT 99183 or HCPCS G0277; include clinical justification and indication‑specific documentation per policy.

Prior Authorization

Prior authorization required for Inspire implantation

Inspire hypoglossal stimulator implantation requires prior authorization and documentation that the patient meets the listed clinical criteria (age, AHI within 24 months, CPAP trial/failure/intolerance, BMI, specialist recommendations).

Include sleep testing showing AHI (15–100 events/hr for adults) within 24 months
Document CPAP failure/intolerance or non‑compliance as defined in policy

Prior Authorization

Prior authorization required for hypoglossal neurostimulator procedures

Prior authorization is implied for implantation, revision, or removal of hypoglossal neurostimulator devices and related HCPCS codes; submit required sleep study and specialist documentation with the authorization request.

Include associated CPT/HCPCS codes when requesting authorization (e.g., 64582, 64583; L8679, L8680, L8686)

Billing Rule

Device coding and authorization

Verify device coding and obtain prior authorization as coverage applies only for conditions outlined in the policy; use HCPCS A7020 and E0482 for MI‑E device/interface billing where applicable and confirm member benefits before service.

HCPCS A7020 = interface for cough stimulating device (replacement only)
HCPCS E0482 = cough stimulating device (CoughAssist)

Prior Authorization

RFA prior authorization / medical necessity headline

Radiofrequency ablation (RFA) may be medically necessary for selected pulmonary tumors when the policy's clinical criteria are met; submit prior authorization documenting the indication and how criteria are satisfied.

Prior Authorization

Prior authorization requirement

Prior authorization is implied for RFA procedures billed with CPT 32998 and associated imaging guidance codes (76940, 77013, 77022); include documentation that the lesion(s) meet size, number, and timing criteria per policy.

Document tumor size (≤3 cm), number (≤3 per lung), amenability to complete ablation, and interval before repeat ablation (≥12 months if applicable)

Prior Authorization

Prior authorization required for continued device rental/purchase

Continued rental or purchase of CPAP, BiPAP, or ASV requires prior authorization demonstrating diagnostic criteria, demonstrated adherence, and minimum rental periods (CPAP/ASV: initial 3‑month rental; BiPAP: initial 7‑month rental).

Adherence requirement: ≥4 hours/night for 70% of nights over 30 consecutive days
CPAP (E0601) must be tried and documented ineffective before BiPAP is authorized

Documentation Required

Home sleep testing physician requirements

Physician services for home sleep testing (G0398, G0399, G0400) must be provided by physicians with appropriate training/board certification and should be performed as part of a comprehensive sleep evaluation for patients with high pretest probability of moderate‑to‑severe OSA.

Ensure the performing physician meets recognized board certification/credentials listed in policy

Prior Authorization

Prior authorization / coverage requirement

Polysomnography requires prior authorization/coverage documentation that the study will alter the patient's treatment plan and that the indication matches a covered condition; include relevant clinical rationale and billing codes.

Document how PSG results will change management and specify the covered clinical indication

Step Therapy

Medication optimization required

Policy requires prior trials of controller medications (inhaled corticosteroids and LABA) for six months prior to a bronchial thermoplasty (BT) request; provide documentation (e.g., pharmacy claims) showing medication use/adherence for the 6‑month period.

Submit pharmacy claims or other records that document 6 months of inhaled LABA + inhaled corticosteroid therapy

Step Therapy

Conservative therapy requirement

For emphysema EBV placement, document failure of optimal medical management and pulmonary rehabilitation prior to valve placement; EBV coverage is limited to one lobe and requires meeting all listed physiologic and imaging criteria.

Provide CT confirmation of emphysema and evidence of failed medical therapy and rehabilitation

Step Therapy

Optimization of medical therapy before procedure

Document optimization of medical therapy and pulmonary rehabilitation prior to EBV procedure; trials and documentation of optimized medical management used in trials are expected for candidate selection.

Billing Rule

Rental trial

A rental trial prior to purchase of certain durable respiratory equipment may be required depending on the member's plan; confirm authorization and rental‑trial requirements with benefits verification.

Step Therapy

Conservative therapy required before HBO2

For chronic diabetic wounds, HBOT is covered only after failure of an adequate 30‑day course of standard wound therapy; include documentation of the 30‑day standard therapy components and failure to heal.

Standard wound therapy should include vascular assessment, nutrition/glucose optimization, debridement, moist dressings, off‑loading, and infection treatment

Step Therapy

Conservative therapy prerequisite

HBOT is generally reserved as a last‑resort therapy when other treatment options are exhausted; prior conservative/standard therapies and rationale for HBOT must be documented in the prior authorization.

Step Therapy

Step therapy: CPAP first

CPAP or other standard therapies must have been tried and documented as failed or intolerable before Inspire implantation is covered; include CPAP trial documentation in the authorization.

Document CPAP failure (AHI >15 on CPAP) or CPAP intolerance (defined in policy) or ≥6 months non‑compliance

Step Therapy

CPAP trial requirement

Policy requires documentation of a CPAP trial and defined evidence of CPAP failure, intolerance, or non‑compliance prior to coverage of Inspire therapy; CPAP failure/intolerance definitions and the non‑compliance timeframe are specified in the policy revision history and criteria.

CPAP failure: AHI > 15 despite CPAP usage
CPAP intolerance: <4 hours/night on ≥5 nights/week
Non‑compliance: documented for at least 6 months

Step Therapy

CPAP must be tried before BiPAP (E0601)

CPAP (HCPCS E0601) must be tried and documented as ineffective with troubleshooting of interface fit, pressure settings, and other issues before BiPAP is authorized.

Document that interface fit, CPAP pressure settings, and other issues were addressed prior to initiation of BiPAP

Documentation Required

Medication adherence documentation

Documentation must demonstrate medication use/adherence (including inhaled LABA and inhaled corticosteroids) for the 6 months immediately prior to a BT request; acceptable evidence includes pharmacy claims.

Provide pharmacy claims or medication fill records covering the 6‑month period prior to request

Documentation Required

Pulmonary function testing

Provide abnormal pulmonary function tests performed within the last 6 months prior to the request to demonstrate objective impairment per policy thresholds.

PFTs must be recent (within 6 months) and show deficits required by the specific policy criteria

Note

Provider and member contact

For benefits or coverage questions contact Select Health Provider Relations; members should consult Customer Service for benefit specifics as listed on the member ID card prior to requesting services.

Provider Relations: (801) 442‑3692
Members: call phone number on member ID card for Customer Service

Documentation Required

Pre-procedure clinical documentation

Pre‑procedure clinical documentation for EBV must include CT confirmation of emphysema, smoking cessation duration (≥4 months), BMI, steroid dosing, PFT values (FEV1, TLC, RV), six‑minute walk distance, and assessment of target‑lobe collateral ventilation by both StratX and Chartis when EBV is for lung volume reduction.

CT scan confirming emphysema
Smoking cessation ≥4 months
PFTs with FEV1, TLC, RV and 6‑minute walk distance per policy thresholds
StratX analysis and Chartis confirmation of collateral ventilation

Billing Rule

Coding and procedure documentation

Include procedure CPT codes for insertion and removal of bronchial valves (31647, 31648, 31649, 31651) and documentation of bronchoscopy with fluoroscopic guidance and the lobe(s) treated when submitting claims and authorization requests.

Documentation Required

Documentation required for neuromuscular disorder coverage

Pulmonary evaluation or consultation is required for MI‑E coverage when used for neuromuscular disorders; document failed standard treatments, pattern of hospitalizations or clinical deterioration, and need for a rental trial if required by plan.

Document prior failed chest physiotherapy (≥ twice daily) when applicable
Include pulmonary consult and hospital course pattern

Documentation Required

Documentation for CO poisoning

For carbon monoxide intoxication, document exposure confirmation and CoHb levels when available; treatment is approved only if started less than 24 hours from poisoning.

Document CoHb level (>10% adults; >5% children/nonsmokers) and timing of treatment (<24 hours)

Documentation Required

CO poisoning documentation

Documentation confirming CO exposure (e.g., CoHb level, gas company or fire department reports) and that treatment was initiated less than 24 hours from exposure is required to approve HBOT for acute symptomatic carbon monoxide intoxication.

Documentation Required

Required documentation for Inspire implant

For Inspire hypoglossal neurostimulation coverage, required documentation includes patient age, AHI results within 24 months, CPAP failure or intolerance/non‑compliance evidence, and recommendations from ENT and sleep specialists.

AHI documented by polysomnography or home sleep testing within 24 months
Specialist recommendations from ENT and sleep medicine

Documentation Required

Required documentation for Inspire UAS

For Inspire UAS authorization, include sleep testing results (polysomnography or home sleep testing within 24 months), the AHI value (15–100 events/hr for adults), BMI (<40 kg/m2), and CPAP usage or intolerance documentation; include applicable CPT codes when submitting.

Documentation Required

Required documentation for MI-E devices

For MI‑E device coverage, document the qualifying neuromuscular disorder or significant impairment of chest wall/diaphragmatic movement and prior ventilation status or hospitalization history that support medical necessity.

Note

Administrative contacts and benefit verification

Providers should verify benefits and eligibility with Customer Service or Select Health Provider Relations prior to service; benefits are determined by the member's individual plan.

Billing Rule

Billing codes provided

Billing CPT codes for MESOMARK testing are provided for informational purposes (e.g., 86316, 86945) but the MESOMARK test is labeled Not covered/investigational for this indication.

CPT 86316, 86945 listed for billing
MESOMARK test considered investigational/not covered

Documentation Required

Required documentation

Documentation for RFA prior authorization should support the clinical indication and include procedure details consistent with covered CPT codes (32998) and imaging guidance codes as applicable.

Documentation Required

Demonstrated adherence must be documented

Demonstrated adherence to PAP therapy must be documented via direct download or visual inspection of device usage showing at least 4 hours per night on 70% of nights over a consecutive 30‑day period when required for continued device coverage.

Adherence metric: ≥4 hours/night for 70% of nights over 30 consecutive days
Assessment via device direct download or visual inspection of usage data

Documentation Required

Credentials and documentation

Sleep center affiliation and physician/staff credentials must be documented and available upon request; centers should maintain certification documentation (AASM, The Joint Commission, or ACHC) per policy.

Maintain AASM, The Joint Commission, or ACHC credentialing documentation for sleep centers
Document technician and physician credentials as listed in policy

Billing Rule

Clinical indication and billing

Document the clinical indication showing the study will alter the treatment plan and that it matches a covered condition when billing for polysomnography or home sleep testing; billing must correspond to covered conditions only.

Denial Risk

Experimental/Investigational triggers denial

Use outside the specified coverage criteria is considered experimental/investigational and may be denied; ensure requested services and indications conform to policy criteria before submission.

Denial Risk

Benefit determination note

Coverage and benefits are determined by the member's individual benefit plan; inclusion or exclusion of procedure or device codes in this policy does not by itself guarantee member coverage and claims may be denied if not covered under the contract.

Denial Risk

Device and labeling compliance

Coverage is limited to FDA‑approved devices used according to FDA labeling and—for EBV lung volume reduction—limited to one lobe; failure to document FDA approval and use consistent with labeling may trigger denial.

EBV coverage requires FDA‑approved device used per labeling and limited to one lobe

Denial Risk

Evidence insufficiency for air leaks

Evidence for endobronchial valves to treat persistent air leaks is limited to small uncontrolled series and is insufficient to determine risk/benefit; such use may be denied or considered non‑covered.

Denial Risk

Common denial triggers

Charges for set‑up, training, or extended warranty associated with HFCWC devices are not eligible for reimbursement and will be denied; chest physiotherapy as a duplicate outpatient service will be denied if an HFCWC device is approved.

Do not bill separately for set‑up, training, or extended warranty

Denial Risk

Additional visits require MD review

Requests for additional treatment visits beyond the initial HBOT course require documentation of substantial improvement and must be submitted for MD review; utilization review is required when quantity limits have been reached.

Provide objective documentation of clinical improvement to justify additional HBOT sessions

Denial Risk

Not covered HCPCS

Topical hyperbaric oxygen chamber, disposable (HCPCS A4575) is not covered and use of this HCPCS code may trigger claim denial.

Do not submit claims for A4575 as it is listed Not covered

Denial Risk

Exclusion-driven denials

Exclusions added to the HBOT policy (e.g., arterial/ischemic ulcers) may trigger denials when services are claimed for excluded indications; verify the indication matches a covered condition.

Denial Risk

CPAP documentation requirement

Lack of documentation demonstrating CPAP failure, CPAP intolerance, or at least 6 months of non‑compliance may trigger coverage denials for Inspire UAS requests; include CPAP usage data and defined failure/intolerance documentation.

CPAP failure: AHI >15 despite CPAP
CPAP intolerance: <4 hours/night on ≥5 nights/week
Non‑compliance: documented ≥6 months

Denial Risk

Contraindications for MI-E

Presence of contraindications such as history of bullous emphysema, lung cysts, susceptibility to pneumothorax/pneumomediastinum, or recent barotrauma are listed contraindications for MI‑E and would lead to non‑coverage.

Screen for history of bullous emphysema, lung cysts, pneumothorax risk, or recent barotrauma before requesting MI‑E

Denial Risk

Coverage tied to conditions outlined in

Coverage is tied strictly to the specific conditions and clinical criteria outlined in the policy; absence of those conditions or failure to meet criteria may result in non‑coverage.

Denial Risk

Coverage denial risk for MESOMARK

The MESOMARK (SMRP) test is labeled Not covered/Investigational for this indication and submitting for this test may result in denial.

Denial Risk

Denial triggers

Failure to meet modified RFA coverage criteria (e.g., ablating >3 tumors per lung, tumors not amenable to complete ablation, or attempting repeat ablation before 12 months) may trigger denial of payment for RFA procedures.

Ensure tumor number, size, location, amenability to complete ablation, and interval criteria are documented

Denial Risk

Home sleep study member age and exclusions

Home sleep study coverage requires the member be ≥15 years and absence of specified high‑risk conditions (heart failure, neuromuscular disease, moderate‑to‑severe COPD, history of stroke, chronic opioid use) and certain comorbidities; failure to meet these criteria may result in denial.

Denial Risk

Appropriate use and comorbidity exclusions for home sleep testing

Home sleep testing is intended only for OSA diagnosis and is not appropriate for patients with significant comorbidities (moderate‑to‑severe pulmonary disease, neuromuscular disease, or congestive heart failure); use outside these indications may be denied.

Denial Risk

Medical necessity affects coverage

Polysomnography coverage depends on whether the study will alter the patient's treatment plan; lack of documentation that the study will change management could lead to denial.

Use in policyPatients must meet EPR3 severe persistent asthma definition to be eligible for BT coverage

Alair Bronchial Thermoplasty System — FDA PMA referenced

DeviceAlair Bronchial Thermoplasty System (Alair Catheter and Alair RF Controller) — FDA Premarket Approval referenced

Regulatory yearPMA referenced April 27, 2010

ContextFDA approval noted in policy references for BT device

Endobronchial valve (EBV) definition

DefinitionEndobronchial valve (EBV) is a bronchoscopically placed one-way valve that prevents inspiratory airflow into a targeted diseased lung region while allowing expiratory airflow to escape

IndicationsUsed to treat persistent air leaks or reduce hyperinflation in severe emphysema (one lobe coverage) when criteria met

Pre-procedure assessmentTarget lobe collateral ventilation should be assessed (StratX and confirmed by Chartis) prior to placement

StratX definition — quantitative CT analysis service

DefinitionStratX is a cloud-based quantitative CT analysis service to evaluate fissure completeness and guide target selection for EBV placement

PurposeGenerates prioritization of target lobes for EBV based on fissure completeness

RoleUsed pre-operatively as part of target selection and to predict EBV success

Chartis definition — physiologic measurement during bronchoscopy

DefinitionChartis is a catheter-based physiologic measurement performed during bronchoscopy to measure collateral ventilation and confirm StratX assessment prior to EBV deployment

TimingPerformed during bronchoscopy at time of anticipated valve placement

PurposeConfirms low collateral ventilation to increase likelihood of effective lung volume reduction

VENT trial definition — RCT of Zephyr EBV (n=321)

DefinitionVENT trial: randomized controlled trial of Zephyr endobronchial valves in heterogeneous emphysema (n=321)

Key eligibilityFEV1 15–45% predicted; TLC >100% predicted; RV >150% predicted; 6-minute walk >=140 m post-rehabilitation

OutcomesPrimary outcomes included percent change in FEV1 and 6-minute walk distance at 6 months

Persistent air leak use definition for EBV

DefinitionPersistent air leak use: EBV placement to occlude airways supplying areas with prolonged air leak when refractory to standard management

EvidenceAvailable evidence limited to uncontrolled small case series; IBV Valve System HDE limited use guidance also noted

Coverage notePolicy allows EBV for bronchopleural fistulas refractory to standard management with device-specific limitations

HFCWC definition — high-frequency chest wall compression vest therapy

DefinitionHigh-frequency chest wall compression (HFCWC) is therapy delivered via an inflatable vest connected to an air-pulse generator that rapidly inflates and deflates to mobilize airway secretions

IndicationsUsed for CF, immotile cilia syndrome, bronchiectasis, and select neuromuscular disorders when criteria met

Coverage constraintRental trial prior to purchase may be required; duplicate outpatient chest physiotherapy will be denied if device approved

Bronchiectasis definition

DefinitionBronchiectasis: chronic cough with daily production of mucopurulent sputum for months to years associated with airway dilatation and bronchial wall thickening

Clinical relevanceOne of the covered conditions for HFCWC devices when criteria are met

Typical managementIncludes chest physical therapy and airway clearance techniques prior to device consideration

HBO2/HBOT definition

DefinitionHyperbaric oxygen therapy (HBO2/HBOT): therapeutic delivery of 100% oxygen in a pressurized chamber to increase tissue oxygenation

Indications exampleIncludes carbon monoxide intoxication (acute), chronic diabetic wounds after failed standard care, decompression illness, etc.

Treatment limitsVisit limits and timing windows (e.g., start <24 hours for CO poisoning; 20–40 treatments for wound/osteomyelitis) apply

Wagner grade definition for diabetic foot ulcers

Wagner grade systemWagner grade classifies diabetic foot ulcers from Grade 0 (intact skin) to Grade 5 (extensive gangrene)

Coverage relevanceChronic diabetic wounds must be Wagner grade III or higher to qualify for HBOT per policy

Clinical implicationDocument Wagner grade in wound assessment prior to HBOT authorization

Carboxyhemoglobin (CoHb) definition and thresholds

DefinitionCarboxyhemoglobin (CoHb) is a laboratory measure used to help confirm carbon monoxide exposure

Adult threshold> 10% supports exposure in adults

Children/nonsmokers threshold> 5% may support exposure in children or nonsmokers

Idiopathic sudden sensorineural hearing loss (ISSHL) definition

DefinitionIdiopathic sudden sensorineural hearing loss (ISSHL): acute loss of hearing; HBOT has limited/weak evidence as adjunct to steroids for acute cases

Evidence noteCochrane and other reviews indicate modest improvement but clinical significance uncertain; benefit unclear for chronic ISSHL

Policy useHBOT may be considered for acute ISSHL within specified visit limits and criteria

Inspire UAS system definition

DefinitionInspire Upper Airway Stimulation (UAS) system: implanted neurostimulator (generator, breathing sensor lead, stimulation lead) that senses breathing and delivers hypoglossal nerve stimulation to maintain airway patency

ComponentsGenerator, breathing sensor lead, stimulation lead; controlled by external remote

Regulatory noteInspire is FDA-approved device for selected patients with moderate-to-severe OSA

CPAP failure definition

CPAP failure definitionCPAP failure: AHI greater than 15 despite CPAP usage

CPAP intolerance definitionCPAP intolerance: <4 hours per night on ≥5 nights/week or non-compliance for ≥6 months

Policy implicationDocumentation of CPAP failure/intolerance required for Inspire coverage

CPAP intolerance definition

CPAP intoleranceDefined as less than 4 hours per night on 5 nights per week or non-compliance for at least 6 months

UseUsed to establish eligibility for alternative therapies such as Inspire implantation

DocumentationProvide device usage data or clinical documentation demonstrating intolerance/non‑compliance

Hypoglossal neurostimulator (Inspire) definition

DefinitionHypoglossal neurostimulator (Inspire): implantable device with neurostimulator array, pulse generator, and respiratory sensor electrode to stimulate the hypoglossal nerve for OSA treatment

Procedure codesAssociated CPT codes include 64582, 64583, 64584 and related codes; HCPCS device codes L8679/L8680/L8686 listed

Candidate selectionEligibility per policy includes AHI, BMI, CPAP failure/intolerance and specialist recommendations

Mechanical insufflation-exsufflation (MI-E) definition

DefinitionMechanical insufflation-exsufflation (MI-E) is a noninvasive device delivering positive pressure insufflation followed by rapid exsufflation via facemask to augment cough and clear secretions

Device HCPCSCoughAssist device billed with HCPCS E0482; interface billed with A7020 (replacement only)

IndicationsUsed for neuromuscular disorders or ventilatory insufficiency impairing cough/clearance when criteria met

SMRP / MESOMARK definition

DefinitionSMRP / MESOMARK: soluble mesothelin-related peptides measured in serum proposed as tumor marker for malignant mesothelioma

EvidenceLimited data; test labeled Not covered/investigational for this indication in policy

Billing codesCPT codes 86316, 86945 listed for MESOMARK testing/billing info

Radiofrequency ablation (RFA) definition

DefinitionRadiofrequency ablation (RFA): percutaneous imaging-guided insertion of electrode into tumor tissue to thermally destroy tumor cells

Common complicationMost common reported side effect is pneumothorax

Procedure contextOutpatient procedure using imaging guidance (CT/US/MR) with CPT 32998 and related guidance codes

Most common side effect of RFA — pneumothorax

Most common side effectPneumothorax (reported in up to 54% of cases in some reports)

Other adverse eventsPleural effusion, pneumonia, hemothorax, microemboli, hemoptysis; most pneumothoraces do not require chest tube

Clinical implicationDocument risk counseling and monitor post-procedure for complications

CPAP/BiPAP/ASV definitions

CPAP definitionContinuous positive airway pressure delivers a single continuous pressure to prevent upper airway collapse

BiPAP/ASV definitionsBiPAP delivers two pressure levels (inspiratory/expiratory); ASV adjusts ventilatory support based on detected events

RoleUsed as primary therapy for OSA; adherence criteria tied to continued device coverage

Polysomnography (PSG) definition

PSG definitionPolysomnography (PSG) is a comprehensive sleep study that always includes sleep staging (EEG, EOG, EMG) plus monitoring of airflow, respiratory effort, and SaO2

Type distinctionsType I (attended PSG) is reference standard; Type II–IV vary by channel counts and monitoring capability

ApplicationPSG required/preferred for many diagnostic and treatment titration decisions in policy

Type I–IV sleep testing definitions

Type I–IV definitionsType I: attended facility PSG with EEG/EOG/EMG/ECG/airflow/effort/SaO2; Type II: minimum 7 channels including EEG to allow AHI; Type III: minimum 4 channels; Type IV: 3+ channels including airflow

ImplicationAcceptable test type depends on clinical indication and ability to calculate AHI/RDI

Policy noteHome sleep testing (Type III/IV) permitted for select patients with high pretest probability of OSA

AHI / RDI thresholds definition

AHI/RDI positive test thresholdsAHI or RDI >=15 events/hour with minimum 30 events OR AHI/RDI 5–14 events/hour with minimum 10 events plus documented qualifying symptoms or comorbidities

Event count ruleIf recording <2 hours, total recorded events must equal the number that would have been required in a 2-hour period

UseDefines positive diagnostic criteria used across sleep-related coverage decisions

Polysomnography PSG repeated definition reference

Repeat PSG guidancePolysomnography may be repeated when clinically indicated; diagnostic and titration criteria apply (split-night, minimum titration durations, event minimums)

Calculation ruleWhen less than 2 hours recorded, total events must meet 2-hour equivalent for AHI/RDI calculation

DocumentationProvide full PSG report including sleep staging and event counts when requesting coverage based on PSG

Modified overall RFA coverage criteria to align with current clinical guidelines and added limits: no more than 3 tumors per lung; tumors must be amenable to complete ablation; wait 12 months before repeat ablation.

2024-10-02added

Added immotile cilia syndrome to list of conditions that qualify for coverage of high-frequency chest wall compression (HFCWC) devices for the Commercial plan.

2024-06-14revised

Expanded Inspire criterion A2 to allow polysomnography or home sleep testing within 24 months of Inspire stimulator consult and maintained AHI 15–100 events/hour and BMI threshold updates.

2024-01-05added

Added criterion #3 to Section II to include Upper Airway Resistance Syndrome diagnosed by polysomnography as an additional qualifying factor for sleep disorder evaluation and treatment.

2023-11-15revised

Added conditions to the policy's list of example exclusions for the Commercial plan.

2023-07-07revised

Lowered the general age requirement for Inspire implantation from 22 to 18 years and added coverage criteria for adolescents with Down Syndrome (ages 13–18).

Policy metadata including effective and review dates, status, and revision flags are provided in the policy header and revision history; see the policy front matter for specific effective and last review dates.