31647
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
4.05
Facility
$185.04
Non-Facility
$185.04
Documentation Required
- Objective measures of exercise capacity (6‑minute walk distance [6MWD], cycle ergometry) and documentation of baseline exercise tolerance; many trials used 6MWD and exercise testing as selection/endpoint measures.
- Documentation of prior optimized medical therapy, enrollment/completion of pulmonary rehabilitation prior to consideration of BLVR/valve procedures (NICE and trial inclusion criteria require prior pulmonary rehabilitation and optimized pharmacotherapy).
- Assessment of gas trapping/hyperinflation (e.g., TLC >100% predicted, RV >150% predicted or RV >175% for some BTVA recommendations) when selecting patients for BLVR.
- Assessment and documentation that the patient is a non‑smoker or has ceased smoking (many trials required non‑smokers), and documentation of ability to tolerate bronchoscopic procedures/anesthesia.
Key Coverage Criteria
- ICD-10 codes listed as covered diagnoses for the above procedures: J43.0 - J43.9 (Emphysema [except due to alpha-1-antitrypsin deficiency]) and J93.81 - J93.9 (Other pneumothorax and air leak [Recurrence of pneumothorax]).
- CPT/HCPCS codes covered if selection criteria are met (examples listed in policy): 31647, 31648, 31649, 31651, 32141, 32491, 32655, 32672, G0302, G0303, G0304, G0305 (see policy for full code descriptions and coding details).
- Lung volume reduction surgery (LVRS) for patients with advanced chronic obstructive pulmonary disease (COPD) due to emphysema (selected patients).
- LVRS provides a survival advantage for patients with predominantly upper‑lobe emphysema and low baseline exercise capacity (as shown in the NETT trial).
- Bilateral LVRS may produce greater spirometric improvement than unilateral procedures in appropriate candidates.
- Bullectomy (surgical resection of bullae) for giant bullous emphysema (GBE) in which single or multiple large bullae encompass ~30% or more of a hemithorax and compress/replace functional lung tissue.
7 Active Policies
HUMANA-ENDOBRONCHIAL-VALVES-FOR-EMPHYSEMA-MA — Endobronchial Valves for Emphysema - Medicare Advantage
AETNA-CPB-0160 — Lung Denervation Therapy and Lung Volume Reduction Surgery
BCBSIL-SUR706.015 — Bronchial Valves
BCBSMT-SUR706.015 — Bronchial Valves
BCBSNM-SUR706.015 — Bronchial Valves
Related Codes
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