Lung volume reduction surgery (LVRS) is eligible when performed for non-high risk patients with severe non-diffused upper lobe emphysema.

Mountain State will pay for lung volume reduction surgery for severe emphysema (492.8) in accordance with the following criteria:

Patients with low exercise capacity are those whose maximal exercise capacity is at or below 25 watts for women and 40 watts (w) for men after completion of the preoperative therapeutic program in preparation for LVRS.  Exercise capacity is measured by incremental, maximal, symptom-limited exercise with a cycle ergometer utilizing 5 or 10 watts/minute ramp on 30% oxygen after 3 minutes of unloaded pedaling.

Use procedure code 32491 – Removal of lung, other than total pneumonectomy; excision-plication of emphysematous lung(s) (bullous or non-bullous)  for lung volume reduction, sternal split or transthoracic approach, with or without any pleural procedure – to report this service.

A program of diagnostic and therapeutic services designed to prepare the patient for surgery must precede lung volume reduction surgery.  Pre-operative pulmonary surgery services should be reported with codes G0302-G0304.

Lung volume reduction surgery must also be followed by a course of post-operative services.  These services must be performed within 8-9 weeks of the LVRS.  Post-operative services should be reported with code G0305.

NOTE:

Procedure codes G0302-G0305 are facility expenses.

Services performed for conditions other than those described above are not eligible and will be denied as not medically necessary.   A participating, preferred or network provider cannot bill the member for the denied service.

Description

Pulmonary emphysema is a progressive, chronic, disabling lung condition caused by exposure to bronchial irritants, particularly cigarette smoke.  Bronchial irritants cause chronic alveolar inflammation, which gradually destroys the alveolar walls and the alveolar-capillary membrane where gas exchange occurs. As air spaces enlarge and damaged alveolar walls lose their elasticity, resulting pulmonary hyperinflation compresses relatively normal adjacent lung tissue (parenchyma).  As the disease process progresses, patients become increasingly short of breath, unable to continue normal levels of activity.

Most emphysema patients are treated medically with the use of oxygen, bronchodilators, antibiotics (when necessary), pulmonary rehabilitation, and preventive health care.

For those patients with severe emphysema for whom medical treatment no longer improves their quality of life, lung volume reduction is available as a surgical option.  This surgical procedure is designed to remove 25-30% of the most damaged, functionally useless lung tissue.  Removal of hyperinflated lung tissue allows the underlying compressed lung to expand and improve respiratory function.

Pre and post-operative services are designed to maximize the patient’s potential to successfully undergo and recover from this extensive surgery.

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.

Lung volume reduction surgery as a treatment for emphysema may be considered medically necessary in patients with emphysema who meet ALL of the following criteria:

• Predominantly upper lobe emphysema with hyperinflation and heterogeneity (i.e., target areas for removal)


• FEV-1 between 20% and 35% of predicted


• Marked restriction in activities of daily living despite maximal medical therapy


• Age younger than 75 years


• Acceptable nutrition status; i.e., 70% - 130% of ideal body weight


• Ability to participate in a vigorous pulmonary rehabilitation program


• No co-existing major medical problems that would significantly increase operative risk


• Willingness to undertake risk of morbidity and mortality associated with LVRS


• Abstinence from cigarette smoking

PRN References

08/2004, Highmark now pays for Lung Volume Reduction Surgery for severe emphysema

A Randomized Trial Comparing Lung-Volume-Reduction Surgery with Medical Therapy for Severe Emphysema, The New England Journal of Medicine, Vol. 348, 05/2003

A Prospective Evaluation of Lung Volume Reduction Surgery in 200 Consecutive Patients, Chest, Vol. 123, 04/2003

Long-term outcome of bilateral lung volume reduction in 250 consecutive patients with emphysema, The Journal of Thoracic and Cardiovascular Surgery, Vol. 125, 03/2003

Short-term and Long-term Outcomes After Bilateral Lung Volume Reduction Surgery, Chest, Vol. 119, 05/2001