Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-132
Topic: Thoracoscopic Laser Ablation of Emphysematous Pulmonary Bullae
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 07/2005

General Policy Guidelines

Indications and Limitations of Coverage

Scientific evidence does not demonstrate the efficacy of thoracoscopic laser ablation of pulmonary bullae; therefore, this procedure is considered investigational/experimental and is noncovered and billable by a participating physician.

Procedure code 32655 (Thoracoscopy, surgical; with pleurodesis, any method, with excision-plication of bullae, including any pleural procedure) should be used to report this service.

Description

Surgical bullectomy is a procedure used for the palliative treatment of patients with pulmonary bullae associated with compression or crowding of adjacent lung structures. Bullae, large airspaces in the parenchyma of the lung, are common in patients with chronic obstructive bronchitis and emphysema. As the bullae expand and cause compression of the normal pulmonary parenchyma, pulmonary function is diminished resulting in significantly increased dyspnea. Thoracoscopic laser bullectomy is designed to improve pulmonary function by contracting the bullous tissue and effectively shrinking the size of the emphysematous lung.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

32655     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

10/1999, "Thoracoscopic Laser Ablation of Pulmonary Bullae Considered Investigational"

References

A Randomized, Prospective Trial of Stapled Lung Reduction Versus Laser Bullectomy for Diffuse Emphysema, The Journal of Thoracic and Cardiovascular Surgery, Vol. 111, No. 2, Pg. 317-322

Cecil Textbook of Medicine, 4th Edition, Pg. 420, 1998

Current Medical Diagnosis & Treatment, 36th Edition, Pg. 254, 1997

Thoracoscopic Laser Ablation of Emphysematous Pulmonary Bullae, Consortium Health Plans Incorporated Medical Policy Reference Manual, 7.01.36, July 31,1996

Thoracoscopic laser ablation of pulmonary bullae: Radiographic selection and treatment response, Journal of Thoracic and Cardiovascular Surgery, Vol. 107, No. 3, Pg. 883-890

Thoracoscopic Laser Bullectomy: A Prospective Study with Three-Month Results, The Journal of Thoracic and Cardiovascular Surgery, Vol. 112, No. 2, Pg. 319-327

Compliance and Functional Residual Capacity After Staple Versus Combined Staple/Holium Laser Lung Volume Reduction Surgery in a Rabbit Emphysema Model, Annals of Thoracic Surgery, Volume 68, No. 3, September 1999

Lung Volume Reduction Surgery for Diffuse Emphysema (Cochrane Review), The Cochrane Library, Issue I, 2001

Laser/Stapled Bullectomy for Emphysema, UPMC Health System, www.upmc_edu/clc/lrs.htm., February 2001

Animal Model for Thoracoscopic Laser Ablation of Emphysematous Pulmonary Bullae, Lasers Surgical Medical, Volume 18, No. 2, 1996

Unilateral Thoracoscopic Surgical Approach for Diffuse Emphysema, Journal of Thoracic Cardiovascular Surgery, Volume 111, No. 2, February 1996

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Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.