32097
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
13.41
Facility
$769.89
Non-Facility
$769.89
Documentation Required
- No explicit documentation checklist or list of required documents is provided in this policy.
- General requirement (implicit): documentation must demonstrate that the procedure is reasonable and necessary for diagnosis or treatment in accordance with Medicare requirements (clinical findings, diagnostic test results, imaging, pathology, and procedure indications should support medical necessity).
- "In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana and subsidiaries may consider MCG Guidelines." (Humana may reference MCG guidance when assessing documentation/medical necessity).
Key Coverage Criteria
- A lung biopsy is a surgical procedure in which a small portion of the lung tissue is removed for diagnostic evaluation.
- A lung resection is a surgical procedure involving removal of a larger portion of the lung tissue for therapeutic purposes.
- Both procedures may be performed through an open approach (thoracotomy) or a minimally invasive technique (thoracoscopy).
- Coverage is allowed when services are "reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member" (per Medicare requirements and as followed by Humana).
- Diagnostic biopsy of lung infiltrate(s) (e.g., wedge, incisional) — (CPT codes referenced: 32096, 32607).
- Diagnostic biopsy of lung nodule(s) or mass(es) (e.g., wedge, incisional) — (CPT codes referenced: 32097, 32608).
1 Active Policy
HUMANA-LUNG-BIOPSY-AND-RESECTION-MA — Lung Biopsy and Resection - Medicare Advantage
Related Codes
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