LCD/NCD Portal

L29214 LUNG VOLUME REDUCTION SURGERY

 

 

01/01/2012

 

Indications and Limitations of Coverage and/or Medical Necessity

Effective for services performed on or after January 1, 2004. Medicare will only consider LVRS reasonable and necessary when all of the following requirements are met:

• History and Physical Examination:

o Consistent with emphysema; BMI, <31.1 kg/m2 (men) or < 32.3 kg/m2 (women), Stable with <20 mg prednisone (or equivalent) every day.

• Radiographic:

o High Resolution Computer Tomography (HRCT) scan evidence of bilateral emphysema.

• Pulmonary function (pre-rehabilitation):

o Forced expiratory volume in one second (FEV1) <45% predicted (> 15% predicted if age > 70 years).

o Total lung capacity (TLC) > 100% predicted post-bronchodilator.

o  Residual volume (RV) > 150% predicted post-bronchodilator.

• Arterial blood gas level (pre-rehabilitation):

o PCO2 <60 mmHg (PCO2 <55 mmHg if 1-mile above sea level), PO2 > 45 mmHg on room air (PO2 > 30 mmHg if 1-mile above sea level).

• Cardiac assessment:

o Approval for surgery by cardiologist if any of the following are present:

 Unstable angina.

 left-ventricular ejection fraction (LVEF) cannot be estimated from the echocardiogram;

 LVEF <45%.

 Dobutamine-radionuclide cardiac scan indicated coronary artery disease or ventricular dysfunction.

  Arrhythmia (> 5 premature ventricular contractions per minute; cardiac rhythm other than sinus.

 Premature ventricular contractions on EKG at rest).

• Surgical assessment:

o Approval for surgery by pulmonary physician, thoracic surgeon, and anesthesiologist post-rehabilitation.

• Exercise:

o Post-rehabilitation 6-minute walk of > 140 m.

o able to complete 3 minutes unloaded pedaling in exercise tolerance test (pre- and post-rehabilitation).

• Consent:

o Signed consents for screening and rehabilitation

• Smoking:

o Plasma cotinine level <13.7 ng/mL (or arterial carboxyhemoglobin <2.5% if using nicotine products).

o Nonsmoking for 4 months prior to initial interview and throughout evaluation for surgery

• Preoperative diagnostic and therapeutic program adherence:

o Must complete assessment for and program of preoperative services in preparation for surgery

• In addition, the patient must have:

o Severe upper lobe predominant emphysema (as defined by radiologist assessment of upper lobe predominance on CT scan).

o  Severe non-upper lobe emphysema with low exercise capacity.

• Patients with low exercise capacity are those whose maximal exercise capacity is at or below 25 watts (w) for women and 40 w for men after completion of the preoperative therapeutic program in preparation for LVRS.

o Exercise capacity is measured by incremental, maximal, symptom-limited exercise with a cycle ergometer utilizing 5 or 10 watt/minute ramp on 30% oxygen after 3 minutes of unloaded pedaling.

• Effective for services performed on or after November 17, 2005, CMS determines that LVRS is reasonable and necessary when performed at facilities that are:

o Certified by the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) under the LVRS Disease Specific Care Certification Program (program standards and requirements as printed in the Joint Commission’s October 25, 2004, Disease Specific Care Certification Program packet).

o Approved as Medicare lung or heart-lung transplantation hospitals.

• In addition, LVRS performed between January 1, 2004, and May 17, 2007, is reasonable and necessary when performed at facilities that:

o Were approved by the National Heart Lung and Blood Institute to participate in the National Emphysema Treatment Trial (NETT).

o Are approved as Medicare lung or heart-lung transplantation hospitals.

• A list of approved facilities and their approval dates will be listed and maintained on the CMS Web site at www.cms.hhs.gov under Medicare – General Information.

• The surgery must be preceded and followed by a program of diagnostic and therapeutic services consistent with those provided in the NETT and designed to maximize the patient’s potential to successfully undergo and recover from surgery.

o The program must include a 6- to 10-week series of at least 16, and no more than 20, preoperative sessions, each lasting a minimum of 2 hours.

o It must also include at least 6, and no more than 10, postoperative sessions, each lasting a minimum of 2 hours, within 8 to 9 weeks of the LVRS.

o This program must be consistent with the care plan developed by the treating physician following performance of a comprehensive evaluation of the patient’s medical, psychosocial and nutritional needs, be consistent with the preoperative and postoperative services provided in the NETT, and arranged, monitored, and performed under the coordination of the facility where the surgery takes place.

 

 

CPT/HCPCS Codes

 

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

 

 

ICD-9 Codes that Support Medical Necessity

 

492.8 OTHER EMPHYSEMA

 

Documentation Requirements

• The following documentation must be submitted upon request for LVRS:

o History and physical examination.

o HRCT scan.

o Pulmonary function tests (pre-rehabilitation).

o Arterial blood gas levels (pre-rehabilitation).

o Cardiac assessment.

o Surgical assessment.

o Exercise report.

o Consents.

o Smoking evaluation.

o Evidence of preoperative diagnostic and therapeutic program adherence.

Treatment Logic

• Lung Volume Reduction Surgery (LVRS) or reduction pneumoplasty, also referred to as lung shaving or lung contouring, is performed on patients with severe emphysema in order to allow the remaining compressed lung to expand, and thus, improve respiratory function.

 

 

Sources of Information and Basis for Decision

 

CMS Transmittal 27 (Change Request 2688)

 

CMS Transmittal 768, Change Request 4149

 

FCSO LCD 39314, Lung Volume Reduction Surgery, 01/01/2012. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

NCD for Lung Volume Reduction Surgery (Reduction Pneumoplasty) (240.1)

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

 

CMS LCD LUNG VOLUME REDUCTION SURGERY