364 Form

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Medical Policy Lung Volume Reduction Surgery for Severe Emphysema Table of Contents
• Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 364 BCBSA Reference Number: 7.01.71 (For Plan internal use only) Related Policies
• Bronchial Valves, #313 • Outpatient Pulmonary Rehabilitation, #136 Policy
Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Lung volume reduction surgery as a treatment for emphysema may be MEDICALLY NECESSARY in individuals with emphysema who meet ALL of the following criteriaa:

• Predominantly upper lobe emphysema with hyperinflation and heterogeneity (i.e., target areas for removal), AND • Forced expiratory volume in one second (FEV-1):
o For individuals who are younger than 70 years of age, the FEV-1 must be no more than 45% of the predicted value, OR o For individuals who are 70 years of age or older, the FEV-1 must be no more than 45% of the predicted value and greater than or equal to 15% of the predicted value. • Marked restriction in activities of daily living despite maximal medical therapy, AND • Age younger than 75 years, AND • Acceptable nutrition status: i.e., 70–130% of ideal body weight, AND • Ability to participate in a vigorous pulmonary rehabilitation program, AND • No coexisting major medical problems that would significantly increase operative risk, AND • Willingness to undertake risk of morbidity and mortality associated with LVRS, AND • Abstinence from cigarette smoking for at least 4 months.

Lung volume reduction surgery is INVESTIGATIONAL in all other individuals.

a Patient selection criteria are based on the National Emphysema Treatment Trial.

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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) This procedure is performed in the inpatient setting. Commercial PPO and Indemnity This procedure is performed in the inpatient setting.

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. CPT Codes CPT codes: Code Description 32491 Removal of lung, other than pneumonectomy; with resection-plication of emphysematous lung(s) (bullous or non-bullous) for lung volume reduction, sternal split or transthoracic approach, includes any pleural procedure, when performed HCPCS Codes HCPCS codes: Code Description G0302 Preoperative pulmonary surgery services for preparation for LVRS, complete course of services to include a minimum of 16 days of services
G0303 Preoperative pulmonary services for preparation for LVRS, 10 to 15 days of services
G0304 Preoperative pulmonary surgery services for preparation for LVRS, 1 to 9 days
G0305 Post-discharge pulmonary surgery services after LVRS, minimum of 6 days of services
ICD-10 Procedure Codes ICD-10-PCS procedure codes: Code Description 0BBC0ZZ Excision of Right Upper Lung Lobe, Open Approach 0BBC4ZZ Excision of Right Upper Lung Lobe, Percutaneous Endoscopic Approach 0BBD0ZZ Excision of Right Middle Lung Lobe, Open Approach 0BBD4ZZ Excision of Right Middle Lung Lobe, Percutaneous Endoscopic Approach 0BBF0ZZ Excision of Right Lower Lung Lobe, Open Approach 0BBF4ZZ Excision of Right Lower Lung Lobe, Percutaneous Endoscopic Approach 0BBG0ZZ Excision of Left Upper Lung Lobe, Open Approach 0BBG4ZZ Excision of Left Upper Lung Lobe, Percutaneous Endoscopic Approach 0BBH0ZZ Excision of Lung Lingula, Open Approach 0BBH4ZZ Excision of Lung Lingula, Percutaneous Endoscopic Approach 0BBJ0ZZ Excision of Left Lower Lung Lobe, Open Approach

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0BBJ4ZZ Excision of Left Lower Lung Lobe, Percutaneous Endoscopic Approach 0BBK0ZZ Excision of Right Lung, Open Approach 0BBK4ZZ Excision of Right Lung, Percutaneous Endoscopic Approach 0BBL0ZZ Excision of Left Lung, Open Approach 0BBL4ZZ Excision of Left Lung, Percutaneous Endoscopic Approach 0BBM0ZZ Excision of Bilateral Lungs, Open Approach 0BBM4ZZ Excision of Bilateral Lungs, Percutaneous Endoscopic Approach

Description Emphysema Emphysema is an anatomically defined condition characterized by the destruction and enlargement of lung alveoli. It is 1 of the conditions considered as a chronic obstructive pulmonary disease (COPD) along with chronic bronchitis and small airway disease. The pathogenesis of emphysema is primarily related to cigarette smoking, which leads to inflammation and recruitment of immune cells to the terminal air spaces of the lung. The resultant extracellular matrix proteolysis damages the lung. Destruction of the gas- exchanging air spaces and ineffective repair of the extracellular matrix results in airspace enlargement. Emphysema can be characterized into distinct pathologic subtypes. Centriacinar emphysema is most frequently associated with cigarette smoking, is usually most prominent in the upper lobes and superior segments of the lower lobes, and is focal. Panacinar emphysema is characterized by abnormally large air spaces evenly distributed across acini in the lower lobes. It is associated with α1-antitrypsin deficiency. Key pulmonary function parameters are the volume of the first forced expiratory volume in 1 second (FEV1) and the total volume of air exhaled during the spirometry (forced vital capacity [FVC]). Airflow obstruction related to COPD is characterized by the reduced ratio of FEV1/FVC, and a reduction in FEV1 correlates with long- term mortality risk.1,

The 2025 Global Initiative for Chronic Obstructive Lung Disease (GOLD) report states that COPD is 1 of the top 3 causes of death globally and 90% of these deaths occur in low- and middle-income countries.[Global Initiative for Chronic Obstructive Lung Dis.... V.pdf Accessed April 25, 2025.] Evidence exists that the prevalence of the disease is appreciably higher in smokers and ex-smokers compared to non-smokers, in those ≥40 years of age compared to those <40, and in men compared to women; although, in developed countries with less smoking, the prevalence is approximately equal between men and women. The COPD Genetic Epidemiology (COPDGene®) study aimed to determine the influence of race, gender, and GOLD stage on the prevalence of prior COPD diagnosis at enrollment.3, Results revealed that African- American individuals had increased odds of not having a prior COPD diagnosis at all GOLD stages of airflow obstruction versus non-Hispanic White individuals (p<.0001). Women had higher odds of having a prior COPD diagnosis at all GOLD stages versus men (p<.0001).

Lung Volume Reduction Surgery Lung volume reduction is a surgical treatment for patients with severe emphysema. Lung volume reduction surgery can be performed using several surgical approaches to access the lungs inncluding median sternotomy, video-assisted thoracoscopic surgery, and thoracotomy.4, The procedure involves the excision of peripheral emphysematous lung tissue, generally from both upper lobes.

The mechanism of clinical improvement for patients undergoing lung reduction surgery has not been firmly established. However, it is believed that mechanical factors such as elastic recoil and diaphragmatic function are improved by reducing the volume of the hyperinflated diseased lung. In addition to changes in the chest wall and respiratory mechanics, the surgery is purported to correct ventilation-perfusion mismatch and improve right ventricular filling.

Complications from the surgical procedure include death, reintubation, arrhythmias, mechanical ventilation for more than 2 days, pneumonia, wound infection, and persistent air leak.

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Research on lung volume reduction surgery has focused on defining the subgroup of patients most likely to benefit from the procedure. Potential benefits of the procedure (eg, improvement in functional capacity and quality of life) must be weighed against the potential risks of the procedure (eg, the risk of postoperative mortality).

A related policy valuates the use of endobronchial valves for patients with severe or advanced emphysema. Both lung volume reduction surgery and endobronchial valves aim to reduce hyperinflation in patients with emphysema, but they differ in invasiveness and delivery. Bronchial valves are a synthetic one-way valve inserted via bronchoscopy into the most diseased lobe of the lung, allowing air to escape but preventing its re-entry. This process results in volume reduction of the treated lobe, potentially improving lung function and quality of life for selected patients.

Summary Description – Intro Lung volume reduction surgery (LVRS) is proposed as a treatment option for patients with severe emphysema who have failed optimal medical management. The procedure involves the excision of diseased lung tissue to reduce symptoms and improve quality of life.

Summary of Evidence – Intro For individuals who have upper-lobe emphysema who receive lung volume reduction surgery (LVRS), the evidence includes randomized controlled trials (RCTs) and systematic reviews of the trials. Relevant outcomes are OS, symptoms, functional outcomes, quality of life, and treatment-related mortality. Findings from the National Emphysema Treatment Trial (NETT), a multicenter RCT, have suggested that LVRS is effective at reducing mortality and improving quality of life in select patients with severe emphysema. In a subgroup analysis, LVRS offered a survival advantage only to patients not considered at high-risk who had predominately upper-lobe emphysema and low initial exercise capacity. Patients with upper-lobe emphysema, regardless of initial exercise capacity, experienced significant improvement in exercise capacity and quality of life after LVRS. Other, smaller RCTs have generally had similar findings, though they have tended to be underpowered for some outcomes and did not stratify by the distribution of emphysema. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have non-upper-lobe emphysema who receive LVRS, the evidence includes a subgroup analysis of a large RCT. Relevant outcomes are OS, symptoms, functional outcomes, quality of life, and treatment-related mortality. In the subgroup analysis of the NETT. In the subgroup analysis of the NETT, for patients with predominately non-upper-lobe emphysema, there were no significant mortality advantages or symptom improvements found with LVRS. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. Policy History Date Action 8/2025 Annual policy review. Policy updated with literature review through April 25, 2025; no references added. Policy statements unchanged. 8/2024 Annual policy review. Policy statements unchanged. 10/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 8/2022 Annual policy review. References added. Minor editorial refinements to policy statements; intent unchanged. 1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
8/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged.

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8/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 7/2018 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 7/2017 Annual policy review. New references added. 7/2016 Annual policy review. New references added. 8/2015 Annual policy review. New references added. 9/2014 Annual policy review. New references added. 6/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015. 2/2014 Coding information clarified. 8/2013 Annual policy review. New references added. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements.
4/2011 Reviewed - Medical Policy Group - Cardiology and Pulmonology. No changes to policy statements. 11/2010 Annual policy review. Changes to policy statements. 3/2010 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 3/2009 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 3/2008 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 3/2007 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 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. Jameson JL, Fauci A, Kasper DL, et al. Harrison's Principles of Internal Medicine 20th Edition. McGraw- Hill Education: Chicago, IL; 2018.
2. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2025 report. https://goldcopd.org/wp- content/uploads/2024/11/GOLD-2025-Report-v1.0-15Nov2024_WMV.pdf Accessed April 25, 2025.
3. Mamary AJ, Stewart JI, Kinney GL, et al. Race and Gender Disparities are Evident in COPD Underdiagnoses Across all Severities of Measured Airflow Obstruction. Chronic Obstr Pulm Dis. Jul 02 2018; 5(3): 177-184. PMID 30584581
4. National Institute for Health and Care Excellence (NICE). Lung volume reduction surgery for advanced emphysema [IPG114]. 2005. https://www.nice.org.uk/guidance/ipg114/ Accessed April 25, 2025.
5. Fishman A, Martinez F, Naunheim K, et al. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med. May 22 2003; 348(21): 2059-73. PMID 12759479
6. Naunheim KS, Wood DE, Mohsenifar Z, et al. Long-term follow-up of patients receiving lung-volume- reduction surgery versus medical therapy for severe emphysema by the National Emphysema Treatment Trial Research Group. Ann Thorac Surg. Aug 2006; 82(2): 431-43. PMID 16888872
7. Sanchez PG, Kucharczuk JC, Su S, et al. National Emphysema Treatment Trial redux: accentuating the positive. J Thorac Cardiovasc Surg. Sep 2010; 140(3): 564-72. PMID 20723727

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8. Kaplan RM, Sun Q, Naunheim KS, et al. Long-term follow-up of high-risk patients in the National Emphysema Treatment Trial. Ann Thorac Surg. Nov 2014; 98(5): 1782-9. PMID 25201722
9. Lim E, Sousa I, Shah PL, et al. Lung Volume Reduction Surgery: Reinterpreted With Longitudinal Data Analyses Methodology. Ann Thorac Surg. May 2020; 109(5): 1496-1501. PMID 31891694
10. Miller JD, Malthaner RA, Goldsmith CH, et al. A randomized clinical trial of lung volume reduction surgery versus best medical care for patients with advanced emphysema: a two-year study from Canada. Ann Thorac Surg. Jan 2006; 81(1): 314-20; discussion 320-1. PMID 16368389
11. Agzarian J, Miller JD, Kosa SD, et al. Long-term survival analysis of the Canadian Lung Volume Reduction Surgery trial. Ann Thorac Surg. Oct 2013; 96(4): 1217-1222. PMID 23895890
12. Huang W, Wang WR, Deng B, et al. Several clinical interests regarding lung volume reduction surgery for severe emphysema: meta-analysis and systematic review of randomized controlled trials. J Cardiothorac Surg. Nov 10 2011; 6: 148. PMID 22074613
13. van Agteren JE, Carson KV, Tiong LU, et al. Lung volume reduction surgery for diffuse emphysema. Cochrane Database Syst Rev. Oct 14 2016; 10(10): CD001001. PMID 27739074
14. Tiong LU, Davies R, Gibson PG, et al. Lung volume reduction surgery for diffuse emphysema. Cochrane Database Syst Rev. Oct 18 2006; (4): CD001001. PMID 17054132
15. Clarenbach CF, Sievi NA, Brock M, et al. Lung Volume Reduction Surgery and Improvement of Endothelial Function and Blood Pressure in Patients with Chronic Obstructive Pulmonary Disease. A Randomized Controlled Trial. Am J Respir Crit Care Med. Aug 01 2015; 192(3): 307-14. PMID 26016823
16. Pompeo E, Rogliani P, Tacconi F, et al. Randomized comparison of awake nonresectional versus nonawake resectional lung volume reduction surgery. J Thorac Cardiovasc Surg. Jan 2012; 143(1): 47- 54, 54.e1. PMID 22056369
17. Celli BR, Decramer M, Wedzicha JA, et al. An official American Thoracic Society/European Respiratory Society statement: research questions in COPD. Eur Respir Rev. Jun 2015; 24(136): 159-72. PMID 26028628
18. Center for Medicare & Medicaid Services. National coverage determination (NCD) for lung volume reduction surgery (reduction pneumoplasty) (240.1). 2005; https://www.cms.gov/medicare-coverage- database/details/ncd- details.aspx?NCDId=119&ncdver=3&CoverageSelection=National&KeyWord=lung+volume+reductio n+surgery& KeyWordLookUp=Title&KeyWordSearchType=And&clickon=search&bc=gAAAABAAAAAAAA%3d%3 d&. Accessed April 25, 2025.