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ModifiedSelectHealthPolicy 379

Bronchial Thermoplasty for Asthma

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Coverage and medical necessity criteria for bronchial thermoplasty (BT) for treatment of severe persistent asthma for SelectHealth commercial, Medicare (when CMS has no determination), and SelectHealth Community Care (Medicaid) members.

Policy Summary

PayerSelectHealth

PolicyBronchial Thermoplasty for Asthma

Policy CodePolicy 379

Change TypeMultiple material revisions (criteria clarifications, age/threshold updates, procedural limits)

Effective DateAug 16, 2023

Last ReviewJun 19, 2025

Next Review DateN/A

Key ActionObtain prior authorization demonstrating all coverage criteria are met, including recent pulmonary function tests and 6 months of controller medication use.

SourceLink

POLICY UPDATE CHANGES

For Commercial Plan Policy, clarified type of procedures that will be covered for use of endobronchial valves in opening paragraph of criteria: 'Select Health covers FDA approved endobronchial valves (e.g., the Zephyr Valve System) for one lobe only, for either of the following conditions:'

Modified requirement in criterion #1g: 'RV > 150% predicted (Greater than or equal to 200% if homogenous emphysema)'

Added note that Chartis is a catheter-based measurement performed during bronchoscopy to assess collateral ventilation and should be used to confirm the StratX assessment prior to valve deployment.

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

Lowered commercial plan age requirement from 22 years to 18 years and added coverage criteria for adolescents with Down syndrome (ages 13 to 18).

Modified AHI upper limit from 65 to 100 events/hour and allowed polysomnography within 24 months of consult; BMI threshold increased to <40 kg/m2.

Updated documentation requirement definitions for CPAP failure/intolerance/non-compliance specifying AHI >15 despite CPAP or <4 hours/night, 5 nights/week, and non-compliance duration of at least 6 months.

Policy title and subject modified to cover FDA-approved hypoglossal neurostimulators generally, not a single device.

Allowed polysomnography or home sleep testing within 24 months of stimulator consult.

For Commercial Plan Policy, overall coverage criteria were modified to align with current clinical guidelines and three additional procedural requirements were added.

3outpatient procedures in a complete BT treatment course

6 monthsrequired controller medication period

06/19/25most recent policy review date

15–100AHI coverage range (events/hr)

<40BMI threshold

Coverage and Medical Necessity Criteria

Commercial Plan Medical Necessity

Covered when ALL of the following are met:

Main eligibility: Patient has severe persistent asthma defined by Expert Panel Report 3 (EPR3) with continual symptoms limiting physical activity, and frequent nighttime symptoms (≥4 nights/week); and abnormal pulmonary function testing performed within the last 6 months demonstrating appropriate abnormality; and documented use of both inhaled long-acting bronchodilator (LABA) and inhaled corticosteroid for the 6 months immediately prior to the BT request demonstrating ongoing controller therapy/adherence.Pulmonary function testing within 6 months; 6 months documented controller use

Medication adherence may be verified by pharmacy claims; PFTs must be recent.

Additional requirement

Required frequent or persistent steroid boluses to treat exacerbations
Experienced a hospitalization or emergency department visit for asthma despite verified medication adherence

Policy Summary

PayerSelectHealth

PolicyBronchial Thermoplasty for Asthma

Policy CodePolicy 379

Change TypeMultiple material revisions (criteria clarifications, age/threshold updates, procedural limits)

Effective DateAug 16, 2023

Last ReviewJun 19, 2025

Next Review DateN/A

Key ActionObtain prior authorization demonstrating all coverage criteria are met, including recent pulmonary function tests and 6 months of controller medication use.

SourceLink

On This Page

Bronchoscopic lung volume reduction with EBV (Commercial/CHIP)

Covered when ALL of the following are met

Clinical eligibility: Adult patient with hyperinflation associated with severe emphysema in regions with little-to-no collateral ventilation, refractory to optimal medical management, and clinically severely impaired.

Device must be FDA-approved and used per labeling.

Diagnostic and physiologic criteria: Emphysema confirmed by CT scan; smoking cessation ≥ 4 months; BMI < 35 kg/m2; stable COPD on ≤ 20 mg prednisone (or equivalent) daily; 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% predicted; RV >150% (>=200% if homogeneous)

Collateral ventilation assessment: Target lobe must have little or no collateral ventilation confirmed using both StratX quantitative CT analysis and Chartis catheter measurement performed at bronchoscopy.

StratX recommended pre-procedure; Chartis confirms intra-procedure.

Device and scope: Treatment limited to a single lobe using an FDA‑approved endobronchial valve device and performed according to device labeling.

Coverage limited to one lobe only for Commercial/CHIP plans.

Initial Therapy

Select Health covers FDA-approved endobronchial valves for one lobe only when ALL of the following are met (commercial plans):

Advanced emphysema and therapy optimization: Member has advanced emphysema with persistent symptoms despite optimized medical therapy and pulmonary rehabilitation; patient is severely impaired clinically and has been evaluated for alternative therapies.

Optimization of medical management and rehabilitation per trial eligibility expected.

Physiologic and functional thresholds: Physiologic criteria consistent with trial-like eligibility: 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); BMI <35; smoking cessation ≥4 months; stable prednisone ≤20 mg/day.FEV1 15–45%; RV >150% (>=200% if homogeneous)

Exact numeric thresholds reflected in policy thresholds and definitions.

Collateral ventilation and targeting: Imaging and physiologic assessment indicate a suitable target lobe with little or no collateral ventilation as confirmed by StratX quantitative CT analysis and Chartis measurement during bronchoscopy.

StratX should be performed pre-procedure; Chartis confirms intra-procedure.

Single-lobe, FDA-approved device use: A single-lobe treatment plan using an FDA‑approved endobronchial valve is documented and the device will be used according to FDA labeling.

Coverage limited to one lobe only; deviation may trigger denial.

Covered Indications with Conditions and Visit Limits

Covered when ALL criteria specific to the indication are met as stated below.

Acute Idiopathic Hearing Loss: Condition present for < 30 days; formal audiometry demonstrating >30 dB loss across >3 consecutive frequencies; patient receiving concomitant systemic or transtympanic steroids per ENT; initial number of HBOT visits = 10 (additional 10 approvable if >20 dB improvement after initial 10).<30 days; 10 initial treatments

ENT determination and audiology documentation required.

Carbon Monoxide Intoxication: Confirmed exposure to CO; treatment must be started < 24 hours from poisoning; CoHb >10% in adults (or >5% in children/nonsmokers) helps confirm exposure. Treatment approved if initiated within 24 hours.treatment started <24 hours

CoHb may degrade after oxygen; corroborating environmental measures acceptable.

Central Retinal Artery Occlusion: Diagnosis of CRAO with condition present ≤ 24 hours; HBOT regimen = 14 treatments (BID for 1 week) with 90 minutes per session.<=24 hours; 14 treatments

Chronic Diabetic Wounds: Type 1 or 2 diabetes with lower extremity wound Wagner grade III or higher AND failure of an adequate 30-day course of standard wound therapy (vascular assessment, nutrition, glucose control, debridement, moist dressings, off‑loading, infection management). Initial HBOT visits = 20; additional increments of 20 require MD review.20 initial treatments; increments require MD review

Chronic Refractory Osteomyelitis: Unresponsive to conventional medical and surgical management; initial HBOT visits = 40 (up to 60 may be indicated with MD review).40 initial treatments

MD review for additional treatments.

Covered / considered indications

Covered indications and considerations described in these chunks include:

Carbon monoxide (CO) poisoning: Acute symptomatic CO intoxication (with or without cyanide) is an indication for HBOT if exposure is confirmed and treatment is initiated within 24 hours; CoHb >10% (adults) or >5% (children/nonsmokers) helps confirm exposure.treatment <24 hours; CoHb >10% adults; >5% children/nonsmokers

CoHb levels degrade with time and after oxygen; environmental confirmation acceptable.

HBOT as last-resort in selected patients: HBOT is generally reserved as a last resort when other treatment options are exhausted, particularly in elderly, comorbid patients; document prior conservative therapies.

Reported outcomes and risks variable; document prior care.

Idiopathic sudden sensorineural hearing loss (ISSHL): Some evidence suggests HBOT plus conventional therapy may improve outcomes in acute ISSHL (younger patients and severe loss may have greater benefit), but evidence quality is limited and clinical significance uncertain.age <50 may show greater benefit; hearing loss >61 dB noted in some studies

Most studies used concomitant systemic steroids.

Commercial Plan — Adult Hypoglossal Neurostimulator Coverage

Covered when ALL of the following are met

Device and diagnosis: Implantation of an FDA‑approved hypoglossal neurostimulator for moderate-to-severe obstructive sleep apnea (AHI 15–100 events/hour) confirmed by polysomnography or home sleep testing within 24 months of consult.AHI 15–100; sleep testing within 24 months

Device must be FDA-approved.

Apnea type and specialist recommendation: Central and mixed sleep apnea account for <25% of total AHI events; recommendation for the device by both an ENT and a sleep specialist.Central/mixed <25%

Refer to policy for recognized sleep specialist certifications.

Prior CPAP documentation: Documentation of either CPAP failure (AHI >15 despite CPAP usage) OR CPAP intolerance (CPAP use <4 hours/night, 5 nights/week) or documented non-compliance for at least 6 months.

Anatomic and BMI criteria: No anatomic findings that would compromise device performance; BMI <40 kg/m2; dental appliance determined to be inadequate or not clinically appropriate; device must be implanted by an ENT.BMI <40

Polysomnography or HST within 24 months required.

Initial implant coverage criteria

Covered when ALL of the following are met (commercial plan criteria summaries reflected in revision history):

Eligibility and diagnostic criteria: Patient meets age criteria (≥18 years; adolescents 13–18 with Down syndrome may be covered), moderate-to-severe OSA with AHI 15–100 events/hour measured by polysomnography or home sleep testing within 24 months of consult, BMI <40 kg/m2, and device is an FDA-approved hypoglossal neurostimulator.AHI 15–100; BMI <40; sleep testing ≤24 months

Revisions updated AHI upper limit to 100 and allowed sleep testing within 24 months.

Prior therapy and CPAP documentation: Documentation demonstrates CPAP failure (AHI >15 despite CPAP use) or CPAP intolerance (less than 4 hours/night on at least 5 nights/week) or documented non-compliance for at least 6 months.CPAP usage thresholds as specified

As updated in revision history.

Testing recency: Polysomnography or home sleep testing performed within 24 months of the hypoglossal stimulator consult.≤24 months

Revision allowed HST/PSG within 24 months.

Initial and procedural eligibility

Covered when ALL of the following are met

Core indications: Percutaneous RFA performed for treatment of primary or metastatic pulmonary malignancies when clinically indicated and documented (see primary indication specifics).

Document clinical indication, number and size/location of tumors and imaging demonstrating amenability to complete ablation.

Tumor count limit: No more than 3 tumors per lung should be ablated.<= 3 tumors per lung

New commercial-plan requirement added in revision history.

Ablation candidacy: Tumors should be amenable to complete ablation as documented by imaging and interventional assessment.

Requirement added in revision.

Repeat ablation timing: At least twelve months should elapse before a repeat ablation is considered.>= 12 months since prior ablation

Requirement added in revision.

Diagnostic testing coverage

Covered when testing meets device-category technical standards and diagnostic thresholds for obstructive sleep apnea:

Device and technical criteria: Testing must meet category‑specific minimum channel/parameter requirements: Type I (full attended PSG with EEG/EOG/EMG/ECG/airflow/effort/SpO2, etc.); Type II (min 7 channels including sleep staging); Type III (min 4 channels); Type IV (3+ channels including airflow).see device definitions

Type‑specific channel minima defined in policy.

Diagnostic positivity: AHI or RDI ≥ 15 events/hour with minimum 30 events OR AHI/RDI 5–14 events/hour with minimum 10 events plus documented symptoms (excessive daytime sleepiness, impaired cognition, mood disorders, insomnia) or comorbidities (hypertension, ischemic heart disease, history of stroke).AHI/RDI thresholds as specified

If <2 hours of sleep recorded, event count must meet 2‑hour equivalent.

Home sleep testing eligibility: Home sleep testing (G0398/G0399/G0400) is covered when reasonable and necessary for diagnosis in patients with high pretest probability of moderate‑to‑severe OSA and performed by physicians with appropriate training/credentials; not appropriate for persons with listed comorbidities (moderate‑to‑severe pulmonary disease, neuromuscular disease, congestive heart failure).clinical judgment

Home testing not intended for other sleep disorders or asymptomatic screening.

Split‑night CPAP titration: Split‑night study is an acceptable alternative for CPAP titration when diagnostic criteria are met; CPAP titration portion must exceed 3 hours and PSG must document that CPAP eliminates or nearly eliminates respiratory events in REM and NREM sleep.CPAP >3 hours

Initial Pediatric PSG Coverage

Covered when ANY of the following condition groups are met and the study will alter the patient's treatment plan:

Obstructive sleep apnea syndrome and related indications: Includes evaluation to differentiate primary snoring from pathologic snoring; evaluation of disturbed sleep/excessive daytime sleepiness/cor pulmonale/failure to thrive/polycythemia; intensive postoperative monitoring after pharyngeal surgery with risk factors; laryngomalacia with failure to thrive or cor pulmonale; sickle cell disease with nocturnal issues; persistent snoring >4 weeks post‑op; and CPAP/BiPAP titration after diagnostic PSG.

See policy for detailed subcriteria.

Bronchopulmonary dysplasia: PSG indicated only if there is clinical suspicion for an accompanying sleep‑related breathing disorder.

Cystic fibrosis: PSG allowed for patients on supplemental oxygen with positive nocturnal oximetry who develop polycythemia or cor pulmonale, and for patients with hypercapnia while awake.

Neuromuscular disease: Children with chronic neuromuscular impairment (e.g., muscular dystrophy, spinal muscle atrophy, cerebral palsy) are indicated for PSG.

Alveolar hypoventilation: Children with alveolar hypoventilation evidenced by CO2 measurements showing hypercapnia with associated hypoxia.

Billing and Codes

Prior Authorization

Prior Authorization and Benefits Verification

Provider action: Prior authorization required. Authorization and benefits verification are required before scheduling procedures; coverage is contingent on member benefits and program applicability. Obtain time-sensitive approval for confirmed carbon monoxide (CO) poisoning cases. Verify benefits and obtain prior authorization for endobronchial valve (EBV) placement and endobronchial valve procedures. Prior authorization is also required for radiofrequency ablation (RFA) where noted and for bronchial thermoplasty (BT) when used outside specified coverage criteria. Failure to obtain prior authorization or to verify benefits may result in denial or nonpayment.

Authorization and benefits verification required prior to service
Prior authorization required for EBV placement and endobronchial valve procedures
Time-sensitive approval required for CO poisoning cases

Documentation Required

Documentation Requirements and Diagnostic Testing

Documentation and medical necessity requirements: provide recent pulmonary function testing and documented trial and continued use of indicated therapies when required (eg, documented trial of CPAP prior to BiPAP, CPAP titration via split-night when applicable). For hypoglossal neurostimulator coverage, include required documentation such as audiometry and ENT documentation. For neuromuscular disorders and chronic diabetic wounds, include disorder-specific documentation. For suspected CO exposure, include confirmation of exposure per policy. MESOMARK (SMRP) testing is considered in specified diagnostic contexts and must be documented where applicable.

Provide recent pulmonary function testing
Document trial and continued use of prior therapies
Include audiometry and ENT documentation for hypoglossal neurostimulator claims
Document neuromuscular disorders and chronic diabetic wound details
MESOMARK (SMRP) testing considered when indicated

Denial Risk

Denial Risks and Noncovered Services

Denial risks and scope limitations: services not supported by documentation, noncompliance with new criteria, or indications considered investigational will be denied (eg, topical hyperbaric oxygen therapy is not covered). Duplicate outpatient chest physiotherapy claims, non-reimbursable ancillary charges, and use of BT outside specified coverage may be denied. Benefits and eligibility are determined by the member's specific plan; coverage is contingent on those benefits. For Medicare beneficiaries, follow CMS coverage rules where applicable. Noncovered HCPCS and codes not specified in this policy should be verified before billing.

Denial for unsupported indications or noncompliance with new criteria
Topical HBO2 (A4575) not covered
Duplicate outpatient chest physiotherapy may be denied
Non-reimbursable ancillary charges may be denied
Coverage contingent on member benefits; verify for Medicare beneficiaries

Note

Utilization Review and Management

Utilization management: prior authorization requirements include review for prior management of prolonged air leak, optimization of medical therapy prior to procedures, and utilization review after quantity limits. Time-sensitive approvals (eg, CO poisoning) must be requested promptly. Potential triggers for denial include missing preauthorization, insufficient documentation of prior therapy, or failure to meet listed criteria.

Prior management required for prolonged air leak
Optimization of medical therapy required before certain procedures
Utilization review after quantity limits enforced
Time-sensitive approvals must be requested promptly

Billing Rule

Billing and Coding Documentation Requirements

Required coding documentation: Document CPT procedure codes for insertion and removal of bronchial valves as applicable (31647, 31651 for insertion; 31648, 31649 for removal). Include CPT 64570 and 64999 when billed where applicable and supported by documentation for neurostimulation or related procedures. Provide appropriate supporting records to justify use of unlisted code 64999.

Document CPT codes 31647, 31651, 31648, 31649 for bronchial valve procedures
CPT 64570 and 64999 may be billed when supported with documentation

Note

Benefit Determination and Therapy Prerequisites

Benefits determination: Benefits and eligibility are determined by the member's plan and are required prior to authorization. Provider should be aware that denial risks exist for noncompliance with criteria and unsupported indications. For hypoglossal neurostimulator coverage, follow the policy-specific required documentation and benefit applicability. CPAP trial is required before BiPAP; CPAP titration via split-night may fulfill requirements as specified.

Benefits and eligibility are member-specific and must be verified
CPAP trial required before BiPAP; split-night titration acceptable when specified
Denial risks for noncompliance with criteria

Covered CPT CodesCPTCovered

31660	Bronchoscopy with bronchial thermoplasty, 1 lobe
31661	Bronchoscopy with bronchial thermoplasty, 2 or more lobes

Bronchial Valve CPT CodesCPTCovered

31647	Bronchoscopy with assessment and insertion of bronchial valve(s), initial lobe
31651	Bronchoscopy with assessment and insertion of bronchial valve(s), each additional lobe
31648	Bronchoscopy with removal of bronchial valve(s), initial lobe
31649	Bronchoscopy with removal of bronchial valve(s), each additional lobe

Hypoglossal Neurostimulation CPT CodesCPTCovered

64582	Open implantation of hypoglossal nerve neurostimulator
64583	Revision or replacement of hypoglossal neurostimulator
64584	Removal of hypoglossal neurostimulator
64568	Incision for implantation of cranial nerve neurostimulator electrode array
64569	Revision or replacement of cranial nerve neurostimulator electrode array

Hypoglossal Neurostimulation HCPCS/Device CodesHCPCSCovered

C8007	Open implantation of hypoglossal nerve neurostimulator array and pulse generator
C8008	Revision or replacement of hypoglossal neurostimulator array
C8009	Removal of hypoglossal neurostimulator array and pulse generator
C8011	Open implantation of hypoglossal neurostimulator electrode array(s) and receiver
C8012	Revision or replacement of hypoglossal neurostimulator electrode array(s) and receiver
C8013	Removal of hypoglossal neurostimulator electrode array(s) and receiver
L8679	Implantable neurostimulator, pulse generator, any type
L8680	Implantable neurostimulator electrode, each
L8686	Implantable neurostimulator pulse generator, single array, nonrechargeable

Hyperbaric Oxygen CPT/HCPCSmixedCovered

99183	Physician attendance and supervision of hyperbaric oxygen therapy, per session
G0277	Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

Not Covered HCPCSHCPCSNot Covered

A4575

Topical hyperbaric oxygen chamber, disposable - not covered

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior authorization required for bronchial thermoplasty

Prior authorization is required and the request must demonstrate that ALL coverage criteria are met, including EPR3-defined severe persistent asthma, required recent pulmonary testing, and documentation of inhaled LABA plus inhaled corticosteroid use for the 6 months immediately prior to the BT request.

Severe persistent asthma per EPR3 (continual activity-limiting symptoms; frequent nighttime symptoms)
Pulmonary function testing within the last 6 months
Documentation of LABA and inhaled corticosteroid use for 6 months; pharmacy claims may be used to verify adherence
One of: frequent/persistent steroid boluses OR hospitalization/ER visit despite verified adherence

Note

Verify benefits and eligibility before authorization

Verify member eligibility and benefits before applying the medical and payment guidelines; benefits and coverage are determined by the member's individual benefit plan in effect at time of service.

Members may contact Customer Service (number on member ID) for benefit details.
Providers may contact Select Health Provider Relations at (801) 442-3692 with policy questions.

Prior Authorization

Prior authorization: document all EBV eligibility criteria

Prior authorization is required for one-lobe endobronchial valve placement; the request must document that the patient meets all listed criteria (CT-confirmed emphysema, smoking cessation ≥4 months, BMI <35, spirometry/TLC/RV thresholds, six-minute walk distance, and StratX/Chartis assessment) or that the procedure is for bronchopleural fistula refractory to standard management.

Pre-procedure CT confirming emphysema and StratX quantitative CT analysis
Chartis measurement during bronchoscopy to confirm little/no collateral ventilation
Clinical thresholds (e.g., FEV1 15–45% predicted; RV >150% predicted or ≥200% if homogeneous; smoking cessation ≥4 months; BMI <35)

Prior Authorization

Authorization required for EBV procedures (commercial plans)

Prior authorization is required for endobronchial valve procedures consistent with commercial plan criteria; coverage is limited to FDA-approved valves for one lobe only and may require intra-procedure confirmation of collateral ventilation (Chartis) to support valve deployment.

Coverage limited to FDA-approved devices used according to FDA labeling and to one lobe only
Chartis should be used during bronchoscopy to confirm StratX assessment prior to valve deployment

Prior Authorization

Prior authorization and HCPCS for HFCWC devices

Prior authorization is required per plan for high-frequency chest wall compression (HFCWC) devices; coverage applies only for specified indications and plans may require a rental trial before purchase.

Covered indications include cystic fibrosis, immotile cilia syndrome, bronchiectasis, or neuromuscular disorders meeting additional criteria
Rental trial prior to purchase may be required depending on the member's plan

Prior Authorization

Prior authorization and MD review for additional visits

Initial courses of hyperbaric therapy and any additional treatment beyond specified visit limits require prior authorization or MD review; increments beyond initial allowed visits (e.g., additional HBOT sessions) need documentation of continued medical necessity.

MD review required for additional increments (e.g., additional 20-treatment blocks for wounds)
Document substantial improvement when requesting more sessions

Billing Rule

Procedure coding requirement for HBOT

Claims for hyperbaric oxygen therapy (HBOT) should include CPT 99183 to report physician attendance/supervision per session and HCPCS G0277 reported per 30-minute interval for HBOT under pressure.

CPT 99183 — physician attendance and supervision, per session
HCPCS G0277 — hyperbaric oxygen under pressure, per 30-minute interval

Prior Authorization

Prior authorization required for hypoglossal neurostimulator implantation

Select Health will cover implantation of an FDA-approved hypoglossal neurostimulator when clinical criteria are met; prior authorization is required and the policy lists CPT codes for implantation, revision, and removal.

Coverage requires AHI 15–100 events/hour and polysomnography or home sleep testing within 24 months of consult
Documentation of CPAP failure or intolerance is required
CPT codes (e.g., 64582, 64583, 64584) apply for implant/revision/removal

Prior Authorization

Prior authorization and device/code submission for neurostimulator procedures

Prior authorization is required for implantation, revision, and removal procedures and for associated device HCPCS/L codes listed in the policy; submit the applicable CPT and HCPCS/device codes with the authorization request.

Submit CPT codes such as 64582, 64583, 64584 (implant/revision/removal) when requesting authorization
Include applicable HCPCS/device codes (e.g., C8007–C8013, L8679, L8680, L8686) as applicable

Note

Obtain authorization per member benefits before billing

Obtain authorization in accordance with the member's benefit plan before billing; coverage is subject to the member's individual benefit determination and may vary by program.

Verify coverage applicability to Commercial, Medicare, or Medicaid (SelectHealth Community Care) members
If CMS has an applicable determination, Medicare coverage is governed by CMS

Prior Authorization

RFA prior authorization and medical necessity

Radiofrequency ablation (RFA) may be considered medically necessary for selected pulmonary tumors when criteria are met; prior authorization is required and coverage depends on documented medical necessity per policy.

RFA considered when tumor ≤3 cm and located ≥1 cm from central thoracic structures
Provide documentation that surgery/radiotherapy are unsuitable due to comorbidity or to preserve lung function

Prior Authorization

Prior authorization: RFA procedural requirements and limits

Prior authorization is required per policy for RFA covered indications; ensure the requested procedure meets coverage criteria including tumor count limits (no more than 3 tumors per lung), amenability to complete ablation, and timing for repeat ablation (≥12 months).

Maximum tumor size ≤3 cm and minimum distance ≥1 cm from central structures
No more than 3 tumors per lung should be ablated; tumors must be amenable to complete ablation
At least 12 months should elapse before repeat ablation

Prior Authorization

Prior authorization for continued PAP device coverage

Prior authorization is required for continued rental or purchase of PAP devices (CPAP, BiPAP, ASV) after the initial rental period; requests must include documentation of diagnosis, indications, and objective adherence data.

CPAP continued coverage: initial minimum 3-month rental; adherence ≥4 hours/night on ≥70% of nights over 30 days
BiPAP continued coverage: initial minimum 7-month rental; documented CPAP trial (E0601) shown ineffective after addressing interface/pressure
ASV continued coverage: initial minimum 3-month rental; for complex CSA require ≥5 central events/hour and central events >50% of total

Billing Rule

Billing codes for sleep testing — verify authorization requirements

Refer to listed CPT/HCPCS codes for sleep testing and related physician services when billing; some services (including home sleep testing) may require prior authorization depending on payer policy.

Representative codes: G0398, G0399, G0400 (home sleep tests); 95810/95811/95808/95807 (PSG codes); 94660 for CPAP initiation/management
Verify whether prior authorization is required for these services under the member's plan

Prior Authorization

Prior authorization for polysomnography and sleep studies

Polysomnography and related sleep study CPT codes require verification of coverage and are subject to Commercial/CHIP criteria; obtain prior authorization when indicated and document that the study will alter the patient's treatment plan.

Home sleep testing eligibility: age ≥15 and absence of conditions increasing risk of central sleep apnea
Ensure the ordering physician meets board certification requirements listed in policy

Step Therapy

Document prior management before EBV for prolonged air leak

Before considering EBV for a prolonged air leak, document prior standard management such as chest tube placement (most patients in case series had at least one chest tube) and other interventions attempted.

Document prior chest tube(s) and any other measures (e.g., blood patch) attempted before EBV
Note that IBV Valve System use is limited to 6 weeks for prolonged air leak under HDE

Step Therapy

Optimize medical therapy and pulmonary rehabilitation before procedures

Optimize medical therapy and complete pulmonary rehabilitation per trial eligibility and guideline context before considering procedures like endobronchial valve placement or bronchoscopic lung volume reduction.

Confirm failure of optimal medical management and pulmonary rehab
Ensure physiologic thresholds (FEV1, RV, TLC, 6-minute walk) meet policy criteria

Step Therapy

Rental trial may be required before purchase

A rental trial prior to purchase of durable respiratory devices (e.g., HFCWC or MI-E) may be required depending on the member's plan; document results of the rental trial when requesting purchase authorization.

Rental trial requirement varies by plan—verify member benefits
Document effectiveness during rental to support purchase request

Prior Authorization

Quantity-limit increments require MD review

Additional increments beyond initial quantity limits (e.g., extra HBOT treatment blocks or wound therapy sessions) require MD review and documentation of continued medical necessity.

Request for additional 20-treatment increments for diabetic wounds requires MD review
MD review required for extensions beyond listed visit limits

Step Therapy

Document prior conservative therapy before HBOT

HBOT is generally reserved as a last-resort therapy when other conservative or standard treatments have been exhausted; document prior conservative management before requesting HBOT.

Document prior wound care, vascular assessment, nutrition, glucose control, debridement, off-loading, and infection management for diabetic wounds
Note HBOT is often used in elderly, comorbid patients and should follow exhaustion of other options

Step Therapy

Document CPAP trial and failure/intolerance before neurostimulator

Coverage for hypoglossal neurostimulation requires documented CPAP failure or intolerance; CPAP/BiPAP are considered first-line therapy and documentation of prior PAP therapy is required before implant consideration.

CPAP failure defined as AHI >15 despite CPAP usage
CPAP intolerance defined as <4 hours/night on 5 nights/week or documented non-compliance for ≥6 months

Step Therapy

Document CPAP trial (E0601) before BiPAP transition

Before switching from CPAP to BiPAP, document a therapeutic CPAP trial (HCPCS E0601) that was ineffective after addressing interface fit and pressure settings; include evidence that these issues were evaluated and corrected.

Document CPAP trial details and measures taken to address interface fit and pressure
Include objective adherence data and reasons CPAP was ineffective

Documentation Required

Required pre-procedure documentation for EBV

Providers must document pre-procedure data for EBV candidates: CT evidence of emphysema, smoking cessation duration, BMI, stable prednisone dose, spirometry (FEV1), TLC, RV, six-minute walk distance, StratX CT analysis, and Chartis measurement confirming little-to-no collateral ventilation.

CT confirmation of emphysema and StratX quantitative CT analysis
Chartis catheter measurement performed at bronchoscopy
Physiologic thresholds (FEV1, TLC, RV) and six-minute walk distance as specified in policy

Documentation Required

Confirm CO exposure and time-to-treatment for HBOT

To support HBOT for carbon monoxide poisoning, provide confirmation of CO exposure such as elevated carboxyhemoglobin levels or corroborating environmental measurements (fire department or gas company); treatment will be approved only if started within 24 hours of exposure.

CoHb >10% in adults (or >5% in children/nonsmokers) helps confirm exposure
Document time from exposure and ensure HBOT initiation <24 hours to support approval

Documentation Required

Required documentation for RFA — tumors and imaging

For RFA requests, document the clinical indication, number and size/location of tumors, imaging demonstrating amenability to complete ablation, and include CPT codes for the procedure and any imaging guidance.

Include tumor measurements, location relative to central structures, and imaging confirming amenability to complete ablation
Billing/coding: CPT 32998 for RFA; 76940/77013/77022 for imaging guidance as applicable

Documentation Required

Maintain credentialing and accreditation documentation for sleep centers

Sleep centers must maintain credentialing documentation for physicians and technicians and facility accreditation (AASM, The Joint Commission, or ACHC); credentials and accreditation should be available upon request.

Physician qualifications per listed boards (ABSM, ABIM, ABFM, ABP, ABPN, ABOHNS, AOBNP, AOBFP, AOBIM, AOBOO, ABA as noted)
Technologist certifications (RST, BRPT, RPSGT, NBRC, RRT, CPFT, CRT) and facility accreditation documentation

Note

Benefit and coding verification before authorization or billing

Verify member benefits and eligibility prior to applying medical guidelines; coding lists in the policy are informational only and inclusion/exclusion of codes does not guarantee coverage or reimbursement.

Confirm benefit applicability for Commercial, Medicare, or Medicaid members before submitting authorization or claims
Do not assume codes listed in the policy imply coverage—check the member's contract

Denial Risk

Denial risk: BT outside coverage criteria

Use of bronchial thermoplasty outside the specified coverage criteria is considered experimental/investigational and may be denied; ensure documentation demonstrates that all specified criteria are met when requesting authorization.

Requests that do not meet EPR3 severity and treatment trial requirements risk denial
Provide complete supporting documentation (testing, medication history, exacerbation history)

Denial Risk

Denial risk: incomplete EBV eligibility or non‑FDA device use

Coverage is limited to FDA-approved devices used according to FDA labeling and to one lobe only for EBV procedures; failure to document required eligibility criteria (CT, smoking cessation, BMI, spirometry, RV, TLC, 6-minute walk, StratX/Chartis) may lead to denial.

Provide StratX and Chartis results to confirm little-to-no collateral ventilation
Document physiologic thresholds and smoking cessation to support eligibility

Denial Risk

Time-sensitive approval window for CO poisoning HBOT

HBOT for carbon monoxide poisoning is time-sensitive and may be approved only if treatment is initiated within 24 hours of CO exposure; failure to start HBOT within this window could lead to denial.

Document exact time of exposure and time HBOT was initiated
Include CoHb levels or corroborating environmental measurements when available

Denial Risk

Denial triggers for hypoglossal neurostimulator requests

Requests for hypoglossal neurostimulator implantation may be denied if required documentation is missing: age, AHI within specified range, BMI threshold, documented CPAP failure/intolerance/non‑compliance, or recent sleep testing within 24 months.

Required elements: age eligibility, AHI 15–100 events/hour (or adolescent criteria for Down syndrome), BMI <40, polysomnography/HST within 24 months, and CPAP failure/intolerance documentation
Recommendation by both an ENT and a sleep specialist must be documented

Denial Risk

Denial risks for noncompliance with RFA criteria

Requests that do not meet modified RFA criteria (e.g., >3 tumors per lung, tumors not amenable to complete ablation, or repeat ablation requested sooner than 12 months) may be denied; ensure documentation addresses these new limits.

Document tumor count, amenability to complete ablation on imaging, and date of prior ablation if applicable
Provide justification if repeat ablation is requested before 12 months

Denial Risk

Home sleep study exclusion triggers

Home sleep testing is not covered for patients under age 15 or for patients with conditions that increase the risk of central sleep apnea or other exclusionary comorbidities; ordering a home sleep study in these patients may trigger denial.

Exclusions include heart failure, neuromuscular disease, moderate-to-severe COPD, history of stroke, chronic opioid use, seizure disorder, dementia, developmental delay, or morbid obesity
Confirm patient age (≥15) and absence of exclusionary conditions before ordering HST

Denial Risk

Home sleep testing exclusions — comorbidity triggers

Home sleep testing is not appropriate for patients with significant comorbidities (moderate-to-severe pulmonary disease, neuromuscular disease, or congestive heart failure); use of HST in these populations may result in denial.

If comorbidities are present, consider in-lab polysomnography instead and document rationale
Ensure ordering clinician meets credentialing and training requirements

Note

Benefit verification required before authorization

Confirm member benefits and eligibility at time of request; coverage is dependent on the individual's benefit plan and services may be denied if not covered under that plan.

Benefits determination precedes application of medical and payment guidelines
Contact member services or provider relations to verify coverage

Key Clinical Thresholds and Test Requirements

Pulmonary function testing recency — performed in the last 6 months prior to request

RequirementPulmonary function testing performed within the last 6 months prior to the request

PurposeDemonstrates abnormal pulmonary function per EPR3 eligibility for bronchial thermoplasty

VerificationRecent PFTs may be used with medication adherence/pharmacy claims to support eligibility

FEV1 — 15-45% predicted

FEV1 range15–45% predicted

ContextEligibility threshold for bronchoscopic lung volume reduction (Zephyr VENT trial–style physiologic criteria)

DocumentationReport FEV1 percent predicted on recent PFT included in pre-procedure documentation

TLC — >= 100% predicted

TLC threshold>= 100% predicted

RolePart of physiologic criteria for endobronchial valve candidacy

SourceSpecified in EBV coverage criteria and trial eligibility summary

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

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

NoteHigher RV threshold applies when emphysema is homogeneous

UseRequired physiologic criterion for EBV eligibility and documented in pre-procedure testing

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

6-minute walk distance100–500 m (150–500 m if homogeneous emphysema)

FunctionMeasures exercise capacity for EBV candidacy; lower bound differs if emphysema is homogeneous

DocumentationInclude measured 6‑minute walk distance in pre-procedure records

Smoking cessation — >= 4 months

Smoking cessation duration>= 4 months

RequirementDocument smoking abstinence prior to EBV consideration

VerificationRecord in pre-procedure documentation (CT and clinical history)

BMI — < 35

BMI threshold< 35

ContextEligibility criterion for EBV lung volume reduction

DocumentationReport measured BMI in pre-procedure records

AHI — 15 to 100 events per hour for adults; adolescents with Down Syndrome AHI >=10 and <=50

Adult AHI range15 to 100 events per hour

Adolescents with Down syndromeAHI >= 10 and <= 50 (ages 13–18)

Testing windowPolysomnography or home sleep testing must be within 24 months of consult

Apnea-Hypopnea Index (AHI) — 15 to 100 events per hour

AHI/RDI threshold15 to 100 events per hour (positive diagnostic threshold >=15 events/hour)

Alternate criterionAHI/RDI 5–14 events/hour with minimum 10 events plus documented symptoms or comorbidity

Event-count minimumMinimum 30 events when using >=15 threshold; minimum 10 events for 5–14 range

Body Mass Index (BMI) — < 40 kg/meter squared

BMI threshold for hypoglossal neurostimulator< 40 kg/meter squared

ContextPart of implant eligibility criteria for adults; also referenced in revision history

DocumentationInclude measured BMI in device implant pre-procedure records

Maximum tumor size for RFA — <= 3 cm

Maximum tumor size<= 3 cm

IndicationApplies to RFA for isolated peripheral NSCLC and pulmonary metastases per coverage criteria

DocumentationImaging must document tumor size ≤3 cm and amenability to complete ablation

Minimum distance from central thoracic structures — >= 1 cm

Minimum safe distance>= 1 cm from trachea, main bronchi, esophagus, aorta and branches, pulmonary artery, and heart

RationaleEnsures lesion location is appropriate for percutaneous RFA and reduces risk to central thoracic structures

DocumentationCT imaging must show required clearance prior to RFA authorization

Maximum tumors per lung — <= 3 tumors per lung

Max tumors per lung<= 3 tumors per lung

Policy additionNew commercial-plan requirement to limit procedural tumor count

DocumentationProvide imaging and count of lesions per lung in prior authorization

Interval before repeat ablation — >= 12 months

Interval before repeat ablation>= 12 months

ContextRepeat RFA should not be considered before 12 months have elapsed since prior ablation

DocumentationPrior ablation date must be provided when requesting repeat ablation

PAP adherence — >= 4 hours per night on >= 70% of nights over a consecutive 30-day period

Adherence definition>= 4 hours per night on >= 70% of nights over a consecutive 30-day period

AssessmentMeasured via direct device download or visual inspection of usage data

UseRequired to establish continued CPAP/BiPAP/ASV coverage after initial rental period

Central events for complex CSA — >=5 central events per hour and central events >50% of total apneas/hypopneas

Central events threshold for complex CSA>=5 central events per hour AND central events >50% of total apneas/hypopneas

ContextDefines complex/treatment-emergent central sleep apnea for ASV eligibility and confirmation

SourceSpecified in polysomnography/ASV coverage criteria

AHI or RDI thresholds for OSA diagnosis — AHI/RDI >= 15 events/hour (min 30 events) OR AHI/RDI 5–14 events/hour (min 10 events) + symptoms/comorbidity

Diagnosis thresholdsAHI or RDI >=15 events/hour (minimum 30 events) OR AHI/RDI 5–14 events/hour (minimum 10 events) plus documented symptoms or comorbidity

Event-count ruleIf sleep recording <2 hours, event number must equal 2-hour equivalent to calculate AHI/RDI

ReferenceUsed to establish positive test for OSA and to guide CPAP/BiPAP coverage

Type II monitor channel minimum — Minimum 7 channels (EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, SaO2).

Type II minimum channelsMinimum 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, SaO2

CapabilityMonitors sleep staging so AHI can be calculated

Use-caseType II may be used unattended in or out of facility or attended in sleep lab

Type III monitor channel minimum — Minimum 4 channels (2 respiratory movement/airflow, 1 ECG/heart rate, 1 oxygen saturation).

Type III minimum channelsMinimum 4 channels: (at least 2 respiratory movement/airflow), 1 ECG/heart rate, 1 oxygen saturation

FunctionAids diagnosis of OSA; may be used unattended or attended

LimitationDoes not monitor full sleep staging (no EEG/EOG/EMG required)

Type IV monitor channel minimum — 3 or more channels including airflow.

Type IV minimum channels3 or more channels including airflow

NoteType IV devices may not meet higher-category criteria and measure variable parameters

UseUsed to aid diagnosis of OSA in selected patients without major comorbidities

Clinical Background and Definitions

Asthma is a chronic inflammatory airway disorder characterized by variable airflow obstruction and bronchospasm related to increased airway smooth muscle. Bronchial thermoplasty (BT) is a minimally invasive bronchoscopic procedure that applies controlled radiofrequency energy to airway smooth muscle over a course of three outpatient treatments with the intent of reducing airway smooth muscle mass and improving long‑term asthma control in carefully selected patients.

Bronchial thermoplasty (BT) definition — minimally invasive bronchoscopic procedure using controlled RF energy (Alair system referenced).

DefinitionBronchial thermoplasty (BT) is a minimally invasive bronchoscopic procedure using controlled radiofrequency energy to heat and reduce airway smooth muscle, performed in three outpatient procedures about three weeks apart (Alair system referenced).

Device PMAAlair Bronchial Thermoplasty System received FDA premarket approval in 2010

Intended effectProvides long‑lasting asthma control as an adjunct to controller medications in severe persistent asthma

Severe persistent asthma (EPR3) — Severity category referenced from Expert Panel Report 3 used as eligibility requirement for BT.

Severity categorySevere persistent asthma defined by Expert Panel Report 3 (EPR3)

ExamplesContinual symptoms limiting activity; frequent nighttime symptoms (>=4 nights/week)

RoleEPR3 severity category is an eligibility requirement for BT coverage

Alair Bronchial Thermoplasty System — FDA PMA referenced (2010) and device context

DeviceAlair Bronchial Thermoplasty System (Alair catheter and Alair RF controller)

Regulatory statusFDA premarket approval (PMA) referenced in policy (2010)

ContextDevice is the approved system used to perform BT as described in coverage criteria

Endobronchial valve (EBV) definition — one-way valve to reduce hyperinflation

DefinitionEndobronchial valve (EBV) is a bronchoscopically placed one-way valve permitting air exit but limiting air entry to targeted diseased lung regions to reduce hyperinflation or to close persistent air leaks

ExamplesZephyr Endobronchial Valve System described; IBV valve used under HDE for prolonged air leak

Use-caseApplied for severe emphysema with little-to-no collateral ventilation or for refractory bronchopleural fistula/prolonged air leak

StratX — cloud-based quantitative CT analysis service for fissure completeness

ServiceStratX is a cloud-based quantitative CT analysis service that assesses fissure completeness and helps prioritize target lobes for EBV placement

TimingStratX should be performed pre-operatively to guide target selection prior to scheduling bronchoscopy

RoleStratX output is confirmed intra-procedure by Chartis measurement

Chartis — catheter-based measurement during bronchoscopy to assess collateral ventilation

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

TimingPerformed intra-procedure at bronchoscopy to measure airway resistance and collateral ventilation

UseRequired to confirm low collateral ventilation when pursuing EBV per policy

HFCWC vest — device description (inflatable vest and air-pulse generator)

Device descriptionHFCWC vest: inflatable vest connected to an air-pulse generator that rapidly inflates/deflates to compress and release the chest wall

MechanismDelivers high-frequency compressions (up to ~20 times per second) to mobilize secretions

IndicationsCovered for specified conditions (e.g., CF, bronchiectasis, immotile cilia syndrome) with additional criteria for neuromuscular disorders

Hyperbaric oxygen therapy (HBOT) definition

DefinitionHyperbaric oxygen therapy (HBOT): patient placed in pressurized chamber and breathes 100% oxygen to increase tissue oxygen tension and hydrostatic pressure

Physiologic effectElevates tissue oxygen levels and hydrostatic pressure to promote healing

DocumentationPolicy lists multiple covered and non-covered indications and time-sensitive windows (e.g., for CO poisoning)

Radiofrequency ablation (RFA) definition — percutaneous imaging-guided thermal tumor destruction

DefinitionRadiofrequency ablation (RFA): percutaneous, imaging-guided thermal tumor destruction using alternating electrical current to induce tissue necrosis

ProcedureCT-guided percutaneous needle electrode delivers RF energy to heat and ablate tumor with minimal damage to surrounding lung

UseConsidered for selected pulmonary tumors when surgical/radiation options are unsuitable

Polysomnography (PSG) definition — comprehensive sleep study including EEG, EOG, EMG, ECG, airflow, respiratory effort, and oximetry

PSG definitionPolysomnography (PSG) is a comprehensive sleep study including EEG, EOG, EMG, ECG, airflow, respiratory effort, and oximetry

PurposeReference standard (Type I attended PSG) for diagnosis and sleep staging; required parameters listed in policy

Device categoriesType II–IV devices defined by minimum channels; PSG always includes sleep staging

Policy Changes and Revision Notes

2026-03-04revisedLatest

Policy title and subject modified to focus on hypoglossal neurostimulation generally rather than a single device; updated related language accordingly.

2025-10-09clarified

Clarified commercial policy to specify that Select Health covers FDA‑approved endobronchial valves (e.g., Zephyr Valve System) for one lobe only and revised RV threshold wording to '> 150% predicted (>= 200% if homogenous emphysema)'.

2025-10-06revised

Modified pediatric criterion for bronchopulmonary dysplasia to indicate polysomnography is indicated only when there is clinical suspicion for an accompanying sleep‑related breathing disorder.

2025-07-03clarified

Clarified eligible physician board certifications authorized to perform home sleep testing evaluations (listing ABSM, ABIM, ABFM, ABP, ABPN, ABOHNS and others).

2025-06-23revised

Updated definitions and documentation requirements for CPAP failure/intolerance/non‑compliance specifying AHI >15 despite CPAP or <4 hours/night (5 nights/week), and non‑compliance duration of at least 6 months.

2025-03-06revised

For RFA procedures, modified overall coverage criteria to align with clinical guidelines and added procedural requirements: limit ablations to no more than 3 tumors per lung, require tumors be amenable to complete ablation, and require a 12‑month interval before repeat ablation.

2025-01-29revised

Specified numeric thresholds to confirm complex/treatment‑emergent sleep apnea: >=5 central events per hour and central events >50% of total respiratory events.

2025-01-05added

Added Upper Airway Resistance Syndrome (diagnosed by polysomnography with >=5 respiratory‑related arousals/hour plus listed comorbidities) as an additional qualifying factor for certain sleep disorder coverage criteria.

2024-08-23added

Added sleep‑certified anesthesiologists (ABA certified) as eligible physicians to evaluate home sleep studies under Section I, Criterion D.

2024-06-14revised

Allowed polysomnography or home sleep testing within 24 months of hypoglossal neurostimulator consult and updated Adult AHI upper limit to 100 events/hour and BMI threshold to <40 kg/m2 in alignment with FDA‑approved indications.

2024-02-28revised

Modified hypoglossal neurostimulation criteria to reflect updated FDA‑approved indications: AHI range widened to 15–100 events/hour and polysomnography within 24 months allowed.

2024-01-05added

Added an additional qualifying criterion to Section II for sleep disorder evaluation concerning Upper Airway Resistance Syndrome.

2023-11-15added

Added conditions to the list of example exclusions for the Commercial Plan Policy.

2023-07-07revised

Lowered age requirement for hypoglossal neurostimulation general criteria from 22 to 18 years and added coverage criteria for adolescents with Down syndrome (ages 13–18).