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Medical Policy Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 715 BCBSA Reference Number: 6.01.58 (For Plan internal use only) NCD/LCD: N/A

Related Policies
Electromagnetic Navigation Bronchoscopy, #203 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Endobronchial ultrasound guidance with transbronchial needle aspiration (EBUS-TBNA) may be considered MEDICALLY NECESSARY for the evaluation of peripheral pulmonary lesions in individuals with suspected lung cancer when all of the following criteria are met:

• Tissue biopsy of the peripheral pulmonary lesion is required for diagnosis
• The peripheral pulmonary lesion is not accessible using standard bronchoscopic techniques.

EBUS-TBNA Endobronchial ultrasound guidance with transbronchial needle biopsy is considered MEDICALLY NECESSARY for mediastinal staging in individuals with diagnosed lung cancer when all of the following criteria are met:

• The individual is suitable and willing to undergo specific treatment for lung cancer, with either curative or palliative intent
• Tissue biopsy of abnormal mediastinal lymph nodes seen on imaging is required for staging and specific treatment planning
• Abnormal lymph nodes seen on imaging are accessible by EBUS-TBNA biopsy.

Endobronchial ultrasound is considered INVESTIGATIONAL for diagnosis and staging of lung cancer when the above criteria are not met.

Endobronchial ultrasound is considered INVESTIGATIONAL for all other indications.

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Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required. Medicare PPO BlueSM Prior authorization is not required.

CPT Codes / HCPCS Codes / ICD Codes
Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: CPT Codes
CPT codes:

Code Description 31652

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (ebus) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures 31653 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (ebus) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node stations or structures 31654 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transendoscopic endobronchial ultrasound (ebus) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s) (list separately in addition to code for primary procedure[s])

ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description C34.00 Malignant neoplasm of unspecified main bronchus C15.9 Malignant Neoplasm of Esophagus Unspecified C34.01 Malignant neoplasm of right main bronchus C34.02 Malignant neoplasm of left main bronchus C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung

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C34.11 Malignant neoplasm of upper lobe, right bronchus or lung C34.12 Malignant neoplasm of upper lobe, left bronchus or lung C34.2 Malignant neoplasm of middle lobe, bronchus or lung C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung C34.31 Malignant neoplasm of lower lobe, right bronchus or lung C34.32 Malignant neoplasm of lower lobe, left bronchus or lung C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung C34.91 Malignant neoplasm of unspecified part of right bronchus or lung C34.92 Malignant neoplasm of unspecified part of left bronchus or lung C38.3 Malignant Neoplasm Of Mediastinum Part Unspecified C45.0 Mesothelioma Of Pleura C75.5 Malignant Neoplasm Of Aortic Body And Other Paraganglia C77.1 Secondary And Unsp Malignant Neoplasm Of Intrathorac Nodes C77.3 Sec And Unsp Malig Neoplasm Of Axilla And Upper Limb Nodes C78.00 Secondary malignant neoplasm of unspecified lung C78.01 Secondary malignant neoplasm of right lung C78.02 Secondary malignant neoplasm of left lung C78.1 Secondary malignant neoplasm of mediastinum C78.1 Secondary Malignant Neoplasm Of Mediastinum C78.2 Secondary malignant neoplasm of pleura C78.30 Secondary malignant neoplasm of unspecified respiratory organ C78.39 Secondary malignant neoplasm of other respiratory organs C7A.090 Malignant Carcinoid Tumor Of The Bronchus And Lung C7A.8 Other Malignant Neuroendocrine Tumors C85.28 Mediastinal (Thymic) Large B-Cell Lymphoma Nodes Mult Site C96.9 Malig Neoplm Of Lymphoid Hematpoetc And Rel Tissue Unsp D02.20 Carcinoma in situ of unspecified bronchus and lung D02.21 Carcinoma in situ of right bronchus and lung D02.22 Carcinoma in situ of left bronchus and lung D38.1 Neoplasm of uncertain behavior of trachea, bronchus and lung D38.3 Neoplasm Of Uncertain Behavior Of Mediastinum D49.1 Neoplasm of unspecified behavior of respiratory system R04.2 Hemoptysis R91.1 Solitary pulmonary nodule

Description Lung Cancer Individuals who are suspected of having lung cancer may present with widely differing signs and symptoms related to the type of cancer (eg, non-small-cell lung cancer [NSCLC] vs. small-cell lung cancer), its location within the lung, and the stage of disease (ie, localized, locoregionally advanced, metastatic). All 3 of the major parameters of type, location, and the stage will dictate subsequent management of cancer, determining whether it is primarily surgical or requires systemic chemotherapy. Early diagnosis of lung cancer is essential because there is uniformly poor prognosis when cancer is diagnosed later in the disease course.

Approximately 75% to 80% of newly diagnosed lung cancers are NSCLC. The clinical presentation and findings on computed tomography (CT) or a fluorine 18 fluorodeoxyglucose positron emission tomography (PET) scan of the chest will typically permit a presumptive diagnosis of lung cancer and differentiation between NSCLC and small-cell lung cancer. If small-cell lung cancer is suspected based on radiographic

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characteristics and other clinical findings, a diagnosis is made by whatever means is the least invasive (eg, sputum cytology, thoracentesis if an accessible pleural effusion is present, fine-needle aspiration of a supraclavicular node).1, The diagnostic technique to evaluate suspected NSCLC is usually dictated by the apparent stage of the disease. Non-small cell lung cancer can present with extensive infiltration of the mediastinum, defined as a mass with no visible lymph nodes, or it may present as a solitary pulmonary nodule that may be bronchogenic or peripheral. In any patient with suspected NSCLC, the diagnosis should be established by the method that has the most favorable risk-benefit ratio.1,

Diagnosis of Peripheral Pulmonary Nodules Solitary pulmonary lesions are typically identified on plain chest radiographs or chest CT scans, often incidentally. Although most of these nodules will be benign, some will be cancerous. Peripheral lung lesions and solitary pulmonary nodules (most often defined as asymptomatic nodules less than 8 mm) are more difficult to evaluate than larger, centrally located lesions. There are several options for diagnosis; however, none of the methods are ideal for safely and accurately diagnosing malignant disease in all patients.2, Sputum cytology is the least invasive approach.1, Reported sensitivity rates are relatively low and vary widely across studies, and sensitivity is even lower for peripheral lesions. Sputum cytology, however, has a high specificity, and a positive test may obviate the need for more invasive testing.

Flexible bronchoscopy, a minimally invasive procedure, is the most common approach to evaluating pulmonary nodules. The sensitivity of flexible bronchoscopy for diagnosing bronchogenic carcinoma has been estimated at 88% for central lesions and 78% for peripheral lesions.2, For small peripheral lesions less than 1.5 cm in diameter, the sensitivity may be as low as 10%, due to the inability to reach into smaller bronchioles.

Transthoracic (percutaneous) needle aspiration, using CT guidance, can be performed for peripheral nodules that are beyond the reach of traditional bronchoscopy. The diagnostic accuracy of transthoracic needle aspiration tends to be as high or higher than that of flexible bronchoscopy for peripheral lesions; the sensitivity and specificity are both greater than 90%.2, A disadvantage of transthoracic needle aspiration is that a pneumothorax could occur in as many as 15% of patients (range, 1% to 15%). Between 1% and 7% will require chest tube insertion. Positron emission tomography scans are also highly sensitive for evaluating pulmonary nodules yet may miss small lesions less than 1 cm in size. Surgical lung biopsy is the criterion standard for diagnosing pulmonary nodules but is an invasive procedure not indicated for all patients.

Staging of Lung Cancer and Assessment of Mediastinal Involvement The stage of lung cancer (its extent through the body) at diagnosis will directly impact the management approach for each patient.3,4, The first step in staging is to identify whether the patient has the distant metastatic disease (M stage) or if the tumor is confined to the chest; this will determine whether treatment should be aimed at palliation or at a potential cure, respectively. If the primary tumor is confined (T stage), determining whether the mediastinal lymph nodes (N stage) are involved is a crucial factor in guiding therapy.

As with diagnostic procedures, there are a number of options for mediastinal staging. The choice of a noninvasive or invasive staging method is dictated by the patient's condition and whether he or she can tolerate or will elect surgery. Thus, staging procedures may be based on noninvasive imaging methods (ie, CT or PET, or combined PET-CT), or may be fully invasive, such as a mediastinoscopy – a surgical procedure that is performed under general anesthesia and is regarded as the reference standard for staging lung cancer.3,

Recent advances in technology have led to enhancements that may increase the yield of established needle-based diagnostic methods that represent a third approach, between noninvasive and surgical procedures.1, Computed tomography scanning equipment can be used to guide flexible bronchoscopy and bronchoscopic transbronchial needle biopsy but has the disadvantage of exposing the patient and staff to radiation.

Endobronchial Ultrasound with Transthoracic Needle Aspiration

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Among its potential applications, endobronchial ultrasound (EBUS) using ultrasound probes can locate and guide the sampling of pulmonary lesions and mediastinal lymphadenopathy.

There are 2 distinct types of transducers used for EBUS that have specific uses: radial probe and convex probe.

A radial probe EBUS comprises a 20- or 30-MHz rotating transducer to provide high-resolution 360° radial images. The probe is inserted into the airways via a standard therapeutic bronchoscope. With the use of an ultrathin bronchoscope combined with radial probe EBUS through a guide sheath, an endoscopist can reach and visualize the sixth- to eighth-generation bronchi, whereas a traditional bronchoscope can only reach the fourth-generation bronchi. The use of radial probe EBUS imaging allows the physician to verify visually that a lesion has been reached and to maintain a position in the periphery to allow a needle biopsy to be performed for diagnosis.5, These probes do not allow real-time imaging during the biopsy. For biopsy or tissue sampling, the target area is located by radial probe EBUS; the radial probe is subsequently retracted and is replaced with a biopsy or sampling device.

Convex probe EBUS transducers are adjustable within a frequency range of 5 to 12 MHz. Such transducers are incorporated into the structure of a dedicated bronchoscope and provide real-time pie-slice sector views of 50° to 60° parallel to the axis of the bronchoscope. Convex probe EBUS with transbronchial needle aspiration (EBUS-TBNA) also can be used for staging the mediastinal nodes.6, The curved linear probe technology allows real-time visualization and needle aspiration of a lesion. Because EBUS-TBNA of the mediastinal nodes may be performed under conscious sedation, it may be used in patients who are not surgical candidates but for whom accurate staging is needed to guide choice among systemic treatments, particularly targeted systemic agents such as tyrosine kinase inhibitors.7,

Summary Description Endobronchial ultrasound (EBUS) is an imaging technique for adjunctive use with standard flexible bronchoscopy. It provides an ultrasound-generated image of the lungs beyond the airway walls, extending to peribronchial structures and distal peripheral lung lesions. The purpose of EBUS is to facilitate navigation to distal regions of the lungs and biopsy of peripheral pulmonary nodules, especially suspected cancerous lesions. Another intended use of EBUS is to localize and facilitate biopsy of the mediastinal lymph nodes as part of staging for non-small-cell lung cancer. Both techniques primarily use transbronchial needle aspiration (TBNA) of lesions to obtain tissue samples.

Summary of Evidence For individuals who have peripheral pulmonary lesions and suspected lung cancer who receive endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for diagnosis, the evidence includes recent systematic reviews, meta-analyses, and 2 small randomized trials. Relevant outcomes are overall survival, disease-specific survival, test accuracy and validity, and morbid events. Evidence supports a conclusion that EBUS-TBNA has diagnostic performance characteristics for solitary pulmonary lesions similar to those of traditional flexible bronchoscopy with transthoracic needle aspiration. The evidence also indicates that the safety profile of EBUS-TBNA may be better than the profile of other techniques, as reflected by pneumothorax and chest tube insertion rates. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have lung cancer and mediastinal lymph nodes are seen on imaging who receive EBUS-TBNA for staging, the evidence includes systematic reviews and meta-analyses. Relevant outcomes are overall survival, disease-specific survival, test accuracy and validity, and morbid events. Evidence from systematic reviews supports a conclusion that EBUS-TBNA exhibits test performance characteristics similar to other needle-based methods used to stage the mediastinum in patients diagnosed with lung cancer. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

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Policy History Date Action 11/2025 Annual policy review. Policy updated with literature review through July 11, 2025; no references added. Policy statements unchanged. 11/2024 Annual policy review. Policy updated with literature review through July 10, 2024; no references added. Policy statements unchanged. Coding information clarified.
1/2024 Coding information clarified. 11/2023

Annual policy review. Policy updated with literature review through July 14, 2023; no references added. Minor editorial refinements to policy statements; intent unchanged. 11/2022 Annual policy review. No references added. Policy statements unchanged. 10/2021 Annual policy review. Policy statements unchanged. 11/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2018 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2017 Annual policy review. New references added. 3/2016 Annual policy review. New references added. 1/2016 Clarified coding information. 11/2015 Policy statements clarified that all of the criteria in the policy need to be met.
11/2015. 4/2015 New medical policy describing medically necessary, not medically necessary and investigational indications. Effective 4/1/2015. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. Rivera MP, Mehta AC, Wahidi MM. Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. May 2013; 143(5 Suppl): e142S-e165S. PMID 23649436
2. Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. May 2013; 143(5 Suppl): e93S-e120S. PMID 23649456
3. Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. May 2013; 143(5 Suppl): e211S-e250S. PMID 23649440
4. Almeida FA, Uzbeck M, Ost D. Initial evaluation of the nonsmall cell lung cancer patient: diagnosis and staging. Curr Opin Pulm Med. Jul 2010; 16(4): 307-14. PMID 20453649
5. Wang Memoli JS, Nietert PJ, Silvestri GA. Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule. Chest. Aug 2012; 142(2): 385-393. PMID 21980059
6. Colt HG, Davoudi M, Murgu S. Scientific evidence and principles for the use of endobronchial ultrasound and transbronchial needle aspiration. Expert Rev Med Devices. Jul 2011; 8(4): 493-513. PMID 21728734
7. Anantham D, Koh MS, Ernst A. Endobronchial ultrasound. Respir Med. Oct 2009; 103(10): 1406-14. PMID 19447014

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8. Han Y, Kim HJ, Kong KA, et al. Diagnosis of small pulmonary lesions by transbronchial lung biopsy with radial endobronchial ultrasound and virtual bronchoscopic navigation versus CT-guided transthoracic needle biopsy: A systematic review and meta-analysis. PLoS One. 2018; 13(1): e0191590. PMID 29357388
9. Ali MS, Trick W, Mba BI, et al. Radial endobronchial ultrasound for the diagnosis of peripheral pulmonary lesions: A systematic review and meta-analysis. Respirology. Apr 2017; 22(3): 443-453. PMID 28177181
10. Ye J, Zhang R, Ma S, et al. Endobronchial ultrasound plus fluoroscopy-guided biopsy compared to fluoroscopy-guided transbronchial biopsy for obtaining samples of peripheral pulmonary lesions: A systematic review and meta-analysis. Ann Thorac Med. 2017; 12(2): 114-120. PMID 28469722
11. Fielding DI, Chia C, Nguyen P, et al. Prospective randomised trial of endobronchial ultrasound-guide sheath versus computed tomography-guided percutaneous core biopsies for peripheral lung lesions. Intern Med J. Aug 2012; 42(8): 894-900. PMID 22212110
12. Paone G, Nicastri E, Lucantoni G, et al. Endobronchial ultrasound-driven biopsy in the diagnosis of peripheral lung lesions. Chest. Nov 2005; 128(5): 3551-7. PMID 16304312
13. El-Osta H, Jani P, Mansour A, et al. Endobronchial Ultrasound for Nodal Staging of Patients with Non- Small-Cell Lung Cancer with Radiologically Normal Mediastinum. A Meta-Analysis. Ann Am Thorac Soc. Jul 2018; 15(7): 864-874. PMID 29684288
14. Ge X, Guan W, Han F, et al. Comparison of Endobronchial Ultrasound-Guided Fine Needle Aspiration and Video-Assisted Mediastinoscopy for Mediastinal Staging of Lung Cancer. Lung. Oct 2015; 193(5): 757-66. PMID 26186887
15. Wahidi MM, Herth F, Yasufuku K, et al. Technical Aspects of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: CHEST Guideline and Expert Panel Report. Chest. Mar 2016; 149(3): 816-35. PMID 26402427
16. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Non-Small Cell Lung Cancer. Version 7.2025. https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf. Accessed July 11, 2025.