Medical Policy



Subject: Lung Volume Reduction Surgery
Document #: SURG.00022 Current Effective Date:    06/28/2017
Status: Reviewed Last Review Date:    05/04/2017

Description/Scope

This document addresses lung volume reduction surgery (LVRS) which is a surgical treatment for individuals with emphysema involving the excision of peripheral emphysematous lung tissue, generally from both upper lobes. The precise mechanism of clinical improvement for individuals undergoing lung reduction surgery has not been firmly established. However, it is believed that the elastic recoil and diaphragmatic function are improved by reducing the volume of diseased lung. In addition to changes in chest wall and respiratory mechanics, the surgery is suggested to correct ventilation perfusion mismatch and improve right ventricular filling.

Note: For information on related topics, see:

Position Statement

Medically Necessary:

Lung volume reduction surgery (LVRS) is considered medically necessary for individuals with bilateral emphysema who meet ALL of the following criteria:

  1. Generally 75 years old or less, although older individuals may be evaluated on a case-by-case basis; and
  2. Severe bilateral disease warranting intervention, as manifested by a forced expiratory volume after 1 second (FEV1 ) of less than or equal to 45% of predicted; and
  3. Severe upper lobe predominant emphysema (confirmed on computed tomography [CT] scan), or severe non-upper lobe emphysema with low exercise capacity (less than or equal to 25W for females and 40W for males after pulmonary rehabilitation); and
  4. Total lung capacity (TLC) greater than or equal to 100% predicted post bronchodilator and residual volume (RV) greater than or equal to 150% predicted post bronchodilator; and
  5. Partial pressure of oxygen (PaO2 ) on room air greater than or equal to 45 mm Hg (greater than or equal to 30 mm Hg at elevations of 5000 feet or higher); and
  6. Partial pressure of carbon dioxide (PaCO2 ) on room air less than or equal to 60 mm Hg (less than or equal to 55 mm Hg at elevations of 5000 feet or higher); and
  7. Cardiac clearance for surgery if left ventricular ejection fraction (LVEF) is less than 45%, or known coronary artery disease, or significant arrhythmias; and
  8. Post-rehabilitation 6 minute walk of at least 140 meters, and able to complete 3 minute unloaded pedaling in exercise tolerance test; and
  9. Abstinence from smoking for at least 4 months.

Investigational and Not Medically Necessary:

Lung volume reduction surgery (LVRS) is considered investigational and not medically necessary when ANY of the following criteria are present:

  1. FEV1 is less than or equal to 20% of predicted value and either of the following:
    1. Homogeneous (that is, non-heterogeneous) distribution of emphysema as documented on CT, or
    2. Diffusing capacity of carbon monoxide (DL CO) less than or equal to 20% of predicted value; or
  2. Myocardial infarction (MI), unstable angina, or congestive heart failure (CHF) within the previous 6 months and LVEF is less than 45%; or
  3. Pulmonary hypertension (mean pulmonary artery pressure (PAP) is greater than or equal to 35 mm Hg [38 mm at 5000 ft. or higher] or peak systolic PAP is greater than or equal to 45 mm Hg [50 mm at 5000 feet or higher]); or
  4. Diffuse emphysema on CT scan judged unsuitable for LVRS; or
  5. Clinically significant bronchiectasis; or
  6. Inability to participate in pulmonary rehabilitation; or
  7. Predominantly non upper lobe emphysema with high exercise capacity (greater than 25W female or greater than 40W male before or after pulmonary rehabilitation); or
  8. Presence of other serious disease expected to compromise short term or long term (5 year) survival; or
  9. If ALL the medically necessary criteria listed above are not met.
Rationale

The National Heart, Lung and Blood Institute (NHLBI) and the Centers for Medicare & Medicaid Services (CMS) were joint sponsors of the National Emphysema Treatment Trial (NETT). This randomized trial focused on the improvement in overall survival in individuals undergoing lung volume reduction surgery (LVRS), compared to those treated medically. The preliminary results of this study, which focused on the results of 139 high-risk individuals, were published in 2001. High-risk individuals were defined as having an FEV1 less than 20% of predicted and a homogenous distribution of emphysema or a carbon monoxide diffusing capacity less than 20% of predicted. In this group of participants, the surgical mortality was 16% compared to 0% in the medically treated group. Since the publication of these results, the NETT trial altered the participant selection criteria to exclude those individuals with an FEV1 less than 20%, unless the diffusing capacity is greater than 20% of predicted and there is a heterogeneous pattern of emphysema. In 2003, the final results of the NETT trial were published. This report further refined the participant selection criteria for LVRS. After exclusion of the 140 individuals considered to be at high risk (as described above), the authors reported that the mortality was similar in both the surgically and medically treated groups. However, subgroup analysis identified one subgroup of participants who were most likely to benefit from the surgery, that is, participants with predominantly upper lobe emphysema and a low maximal workload after rehabilitation, who had lower mortality and a greater probability of improvement in symptoms if they underwent LVRS, than if they received medical therapy alone.

The subgroup of participants with a combination of non-upper lobe emphysema and a high maximal work load had a higher mortality than the medically treated group and did not have greater functional or symptomatic improvement than participants in the medical therapy group. Participants with upper lobe disease and high exercise capacity and participants with non-upper lobe disease and low exercise capacity had no survival advantage compared to the medically treated group, but did have improvements in function, health related quality of life scores, or both. An updated analysis of the NETT trial data was prepared in 2006, which provided median follow-up of 4.3 years. The clinical benefit, previously noted in the subgroup of participants with predominantly upper lobe emphysema and low exercise capacity, persisted and the authors concluded that, "The effects of LVRS are durable, and it can be recommended for upper lobe-predominant emphysema patients with low exercise capacity…" (Naunheim, 2006b). These findings are consistent with an updated Cochrane review which was conducted to compare the effectiveness of LVRS versus non-surgical standard therapy in improving health outcomes for individuals with severe diffuse emphysema. Secondary objectives included determining which subgroups benefit from LVRS and for which populations with emphysema LVRS is contraindicated. This review of randomized controlled trials also intended to establish the postoperative complications of LVRS, the morbidity and mortality of LVRS, and which surgical approaches for LVRS are most effective. The quality of evidence ranged from low to moderate due to an unclear risk of bias across many studies, lack of blinding and low participant numbers for some outcomes. Eight of the studies compared LVRS versus standard medical care; one compared two closure techniques (stapling vs. laser ablation); one looked at the effect of buttressing the staple line and one compared traditional "resectional" LVRS with a non-resectional surgical approach. Participants completed a mandatory course of pulmonary rehabilitation/physical training before the procedure commenced. The results showed that short-term mortality was higher for LVRS (odds ratio [OR] 6.16, 95% confidence interval [CI] 3.22 to 11.79; 1489 participants; five studies; moderate-quality evidence) than for control, but long-term mortality favored LVRS (OR 0.76, 95% CI 0.61 to 0.95; 1280 participants; two studies; moderate-quality evidence). Participants identified post hoc as being at high risk of death from surgery were those with particularly impaired lung function, poor diffusing capacity and/or homogenous emphysema. Participants with upper lobe-predominant emphysema and low baseline exercise capacity showed the most favorable outcomes related to mortality, and investigators reported no significant differences in early mortality between participants treated with LVRS and those in the control group (OR 0.87, 95% CI 0.23 to 3.29; 290 participants; one study), as well as significantly lower mortality at the end of follow-up for LVRS, compared with control (OR 0.45, 95% CI 0.26 to 0.78; 290 participants; one study). Adverse events were more common with LVRS than with control, specifically the occurrence of (persistent) air leaks, pulmonary morbidity (for example, pneumonia) and cardiovascular morbidity. The authors concluded that LVRS is an effective treatment for selected individuals with severe emphysema and may lead to better health status and lung function outcomes, specifically for those with upper lobe-predominant emphysema with low exercise capacity, but the procedure is associated with risks of early mortality and adverse events (van Agteren, 2016).

Several authors had previously published additional articles related to aspects of LVRS outcomes, most of which were taken from the NETT data (Benzo, 2009; Criner, 2009; DeCamp, 2006; Martinez, 2006; Synder, 2008). In general, their respective findings are consistent with the results reported from the NETT. The following comment from Naunheim and colleagues is noted: "Although lung volume reduction can be performed in selected patients with acceptable mortality, the incidence of major cardiopulmonary morbidity remains high. The lone predictor for operative mortality of LVRS was the presence of non-upper lobe-predominant emphysema" (Naunheim, 2006a). An updated search of the published evidence and updated information from the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) reflects no substantive change in the recommendations for LVRS which are consistent with results of the NETT trial (Agzarian, 2013; Baldi, 2012; Decker, 2014; GOLD, 2014; Kaplan, 2014).

Background/Overview

Emphysema is the fourth leading cause of death in the United States and claims approximately 120,000 lives annually. The most common form of emphysema is referred to as "acquired emphysema" and is typically caused by chronic smoking. A second type, Alpha 1 antitrypsin deficiency-related emphysema (AAT), is a genetic condition, whereby a protein responsible for lung protection is not produced by the body. Approximately 90% of all emphysema deaths are related to acquired emphysema.

The most significant risk factor for the development of emphysema is cigarette smoking. Other forms of smoking, including second-hand smoke, have been identified as risk factors, but are not as significant as smoking cigarettes. Smoking is especially harmful in individuals with AAT.

The symptoms of emphysema range from chronic cough and phlegm production to severely disabling shortness of breath. Symptoms usually progress slowly over time, increasingly limiting breathing ability and often leading to a complete inability to breathe. There is no cure for emphysema, and non-surgical treatment is aimed at relieving symptoms with medication and preventing complications with physical exercise programs, breathing exercises, and education programs.

In emphysema, the walls between the air sacs in the lungs lose elasticity, causing them to remain in the "open" position, which impedes the ability of the lungs to expand and contract during breathing. This, in turn, causes the air in the sac to become stagnant, as the body absorbs the oxygen available and expels carbon dioxide (CO2 ). The diseased "open" sacs further affect the function of the lungs by using more space than normal and crowding the healthy tissues, impeding their function. In later stages of emphysema, as more and more lung tissue becomes diseased, the healthy tissue is further limited in function.

LVRS is a treatment for individuals with specific types of advanced emphysema. LVRS is an extensive, invasive surgical procedure that involves the removal of significant portions of both sides of the lungs, theoretically leaving more space in the chest cavity, into which the remaining less diseased tissue can expand. Various approaches are used to access the lung cavity. Open methods involve either splitting the breastbone (median sternotomy) or making an opening between the ribs on each side of the chest (clamshell incision). An alternative method, Video-Assisted Thoracoscopic Stapled LVRS, uses a camera and long, thin tools to work through small holes in the chest wall. Up to 30% of lung mass may be removed during LVRS, preferably targeting the regions of most severe disease, while preserving lung tissue that is less diseased.

LVRS is not a cure for emphysema. It is intended to alleviate some of the symptoms of the condition, including shortness of breath. Individuals who undergo LVRS continue to have severe emphysema, and their disease will continue to progress over time. This surgery is not hazard-free. The most common complication is creation of an air leak in the lung. Other potential complications include respiratory failure, infection, bleeding, fatigue, rapid heart rate, and death. Recent studies have reported an especially high risk of death in individuals with very advanced emphysema.

At present, alternative treatments to LVRS include medical therapy with rigorous physical therapy programs and lung transplantation.

Definitions

Congestive heart failure (CHF): A type of heart disease where the heart muscle becomes weakened and cannot pump blood as strongly as needed.

Coronary artery disease (CAD): A form of heart disease where the main blood vessels supplying blood to the heart become partially occluded with deposits.

Diffusion capacity of carbon monoxide (DL CO): A test to determine how well oxygen passes from the air sacs of the lungs into the blood.

Ejection fraction (EF): The percent of total volume of blood in the left ventricle of the heart that is ejected when the heart contracts; used as a measure of heart health and function.

Emphysema: A progressive disease of the lungs that leads to difficulty in breathing, decreased ability to exercise and eventually death.

Forced expiratory volume after 1 second (FEV1 ): A measure of the volume of gas expired after one second from the beginning of the forced vital capacity (FVC) maneuver which involves forcefully exhaling into a FEV meter.

Myocardial infarction (MI): A condition where a portion of the heart is deprived of blood due to blockage of a blood vessel, which causes the heart muscle to stop working; also referred to as a heart attack.

Partial pressure of carbon dioxide (PaCO2 ): A measurement that indicates how effectively the lungs are able to rid themselves of a by-product of metabolism, CO2 ; the "normal" range PaCO2 is 35 to 45 mmHg; elevated values greater than 40-45 mainly indicate that the lungs are not able to adequately rid themselves of the CO2 .

Partial pressure of oxygen (PaO2 ): A measure of the actual amount of oxygen that is in the arterial blood; the "normal" PaO2 is generally greater than 75-80 mmHg.

Total lung capacity (TLC): A measure of the air volume of the lungs.

Unstable angina: A condition characterized by chest discomfort that occurs from a temporary lack of blood and oxygen to the heart; stable angina occurs in regular patterns following usual activities, such as exertion; unstable angina does not follow any pattern.

Upper-lobe lung disease: A type of lung disease where the diseased portions are predominantly in the upper lobes of the lungs.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

CPT  
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
32672 Thoracoscopy, surgical; with resection-plication for emphysematous lung (bullous or non-bullous) for lung volume reduction (LVRS), unilateral includes any pleural procedure, when performed
   
HCPCS  
G0302 Pre-operative pulmonary surgery services for preparation for LVRS, complete course of services, to include a minimum of 16 days of services
G0303 Pre-operative pulmonary surgery services for preparation for LVRS, 10 to 15 days of services
G0304 Pre-operative pulmonary surgery services for preparation for LVRS, 1 to 9 days of services
G0305 Post discharge pulmonary surgery services after LVRS, minimum of 6 days of services
   
ICD-10 Procedure  
  For the following procedures when specified as lung volume reduction surgery:
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
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
   
ICD-10 Diagnosis  
J43.1 Panlobular emphysema
J43.2 Centrilobular emphysema
J43.8 Other emphysema
J43.9 Emphysema, unspecified
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection [with emphysema]
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation [with emphysema]
J44.9 Chronic obstructive pulmonary disease, unspecified [with emphysema]

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above, for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

References

Peer Reviewed Publications:

  1. Agzarian J1, Miller JD, Kosa SD, et al. Long-term survival analysis of the Canadian Lung Volume Reduction Surgery trial. Ann Thorac Surg. 2013; 96(4):1217-1222.
  2. Appleton S, Adams R, Porter S, et al. Sustained improvements in dyspnea and pulmonary function 3 to 5 years after lung volume reduction surgery. Chest. 2003; 123(6):1838-1846.
  3. Baldi S, Oliaro A, Tabbia G, et al. Lung volume reduction surgery 10 years later. J Cardiovasc Surg (Torino). 2012; 53(6):809-815.
  4. Berger RL, Decamp MM, Criner GJ, Celli BR. Lung volume reduction therapies for advanced emphysema: an update. Chest. 2010; 138(2):407-417.
  5. Berger RL, Wood KA, Cabral HJ, et al. Lung volume reduction surgery: a meta-analysis of randomized clinical trials. Treat Respir Med. 2005; 4(3):201-209.
  6. 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. 2015; 192(3):307-314.
  7. Decker MR, Leverson GE, Jaoude WA, Maloney JD. Lung volume reduction surgery since the National Emphysema Treatment Trial: study of Society of Thoracic Surgeons Database. J Thorac Cardiovasc Surg. 2014; 148(6):2651-2658.
  8. Deslee G, Mal H, Dutau H, et al; REVOLENS Study Group. Lung volume reduction coil treatment vs usual care in patients with severe emphysema: The REVOLENS randomized clinical trial. JAMA. 2016; 315(2):175-184.
  9. Drazen JM, Epstein AM. Guidance concerning surgery for emphysema. N Engl J Med. 2003; 348(21):2134-2136.
  10. Fishman A, Fessler H, Martinez F, et al. Patients at high risk of death after lung-volume-reduction surgery. N Engl J Med. 2001; 345(15):1075-1083.
  11. 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. 2003; 348(21):2059-2073.
  12. Flaherty KR, Kazerooni EA, Curtis JL, et al. Short-term and long-term outcomes after bilateral lung volume reduction surgery: prediction by quantitative CT. Chest. 2001; 119(5):1337-1346.
  13. Geddes D, Davies M, Koyama H, et al. Effect of lung-volume-reduction surgery in patients with severe emphysema. N Engl J Med. 2000; 343(4):239-245.
  14. Ginsburg ME, Thomashow BM, Yip CK, et al. Lung volume reduction surgery using the NETT selection criteria. Ann Thorac Surg. 2011; 91(5):1556-1561.
  15. Goldstein RS, Todd TR, Guyatt G, et al. Influence of lung volume reduction surgery (LVRS) on health related quality of life in patients with chronic obstructive pulmonary disease. Thorax. 2003; 58(5):405-410.
  16. Hersh CP, DeMeo DL, Reilly JJ, Silverman EK. Xenobiotic metabolizing enzyme gene polymorphisms predict response to lung volume reduction surgery. Respir Res. 2007; 8:59.
  17. Hillerdal G, Lofdahl CG, Strom K, et al. Comparison of lung volume reduction surgery and physical training on health status and physiologic outcomes: a randomized controlled clinical trial. Chest. 2005; 128(5):3489-3499.
  18. Hogg JC, Chu FS, Tan WC, et al. Survival after lung volume reduction in chronic obstructive pulmonary disease: insights from small airway pathology. Am J Respir Crit Care Med. 2007; 176(5):454-459.
  19. 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. 2011; 6:148.
  20. Ingenito EP, Wood DE, Utz J. Bronchoscopic lung volume reduction in severe emphysema. Proc Am Thorac Soc. 2008; 5(4):454-460.
  21. Kaplan RM, Ries AL, Reilly J, et al. Measurement of health-related quality of life in the national emphysema treatment trial. Chest. 2004; 126(3):781-789.
  22. 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. 2014; 98(5):1782-1789.
  23. Lederer DJ, Thomashow BM, Ginsburg ME, et al. Lung-volume reduction surgery for pulmonary emphysema: improvement in body mass index, airflow obstruction, dyspnea, and exercise capacity index after 1 year. J Thorac Cardiovasc Surg. 2007; 133(6):1434-1438.
  24. Leyenson V, Furukawa S, Kuzma AM, et al. Correlation of changes in quality of life after lung volume reduction surgery with changes in lung function, exercise, and gas exchange. Chest. 2000; 118(3):728-735.
  25. Martinez FJ, Chang A. Surgical therapy for chronic obstructive pulmonary disease. Semin Respir Crit Care Med. 2005; 26(2):167-191.
  26. Maxfield RA. New and emerging minimally invasive techniques for lung volume reduction. Chest. 2004; 125(2):777-783.
  27. Miller JD, Berger RL, Malthaner RA, et al. Lung volume reduction surgery vs. medical treatment for patients with advanced emphysema. Chest. 2005; 127(4):1166-1177.
  28. Sanchez PG, Kucharczuk JC, Su S, et al. National Emphysema Treatment Trial redux: accentuating the positive. Gen Thorac Cardiovasc Surg. 2010; 140(3):564-572.
  29. Strange C, Herth FJ, Kovitz KL, et al. Design of the Endobronchial Valve for Emphysema Palliation Trial (VENT): a non-surgical method of lung volume reduction. BMC Pulm Med. 2007; 7:10.
  30. Ware JH. The National Emphysema Treatment Trial - how strong is the evidence? N Engl J Med. 2003; 348(21):2055-2056.
  31. Yusen RD, Lefrak SS, Gierada DS, et al. A prospective evaluation of lung volume reduction surgery in 200 consecutive patients. Chest. 2003; 123(4):1026-1037.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Thoracic Society (ATS). Lung volume reduction surgery. May 1996. Available at: https://www.thoracic.org/patients/patient-resources/resources/surgery-for-COPD.pdf . Accessed on March 16, 2017.
  2. American Thoracic Society (ATS). Surgery for COPD. (no date). Available at: https://www.thoracic.org/patients/patient-resources/resources/surgery-for-COPD.pdf . Accessed on March 16, 2017.
  3. Anderson B, Conner K, Dunn C, et al. Diagnosis and management of chronic obstructive pulmonary disease (COPD). Bloomington (MN): Institute for Clinical Systems Improvement (ICSI). January 2016. Available at:  http://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_respiratory_guidelines/copd/. Accessed on March 16, 2017.
  4. Benzo R, Farrell MH, Chang CC,et al. National Emphysema Treatment Trial Research Group (NETT). Integrating health status and survival data: the palliative effect of lung volume reduction surgery. Am J Respir Crit Care Med. 2009; 180(3):239-246.
  5. Blue Cross Blue Shield Association. Lung volume reduction for severe emphysema. TEC Assessment, 2003; 18(17).
  6. Canadian Agency for Drugs and Technologies in Health (formerly known as the Canadian Coordinating Office for Health Technology Assessment [CCOHTA]). Ottawa, ON Canada. Technology Report. Lung volume reduction surgery for emphysema. November 2005. Available at: http://www.cadth.ca/media/pdf/410_LVRS_to_e.pdf. Accessed on March 16, 2017.
  7. Celli BR, MacNee W. American Thoracic Society/European Respiratory Society (ATS/ERS) Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004; 23(6):932-946.
  8. Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations. Lung Volume Reduction Surgery (Reduction Pneumoplasty). NCD #240.1. Effective November 17, 2005. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=119&ncdver=3&DocID=240.1&bc=gAAAAAgAAAAA&. Accessed on March 16, 2017.
  9. Criner GJ, Belt P, Sternberg AL, et al. National Emphysema Treatment Trial Research Group (NETT). Effects of lung volume reduction surgery on gas exchange and breathing pattern during maximum exercise. Chest. 2009; 135(5):1268-1279.
  10. Criner GJ, Scharf SM, Falk JA, et al. National Emphysema Treatment Trial Research Group (NETT). Effect of lung volume reduction surgery on resting pulmonary hemodynamics in severe emphysema. Am J Respir Crit Care Med. 2007; 176(3):253-260.
  11. DeCamp MM, Blackstone EH, Naunheim KS, et al. National Emphysema Treatment Trial Research Group (NETT). Patient and surgical factors influencing air leak after lung volume reduction surgery: lessons learned from the National Emphysema Treatment Trial. Ann Thorac Surg. 2006; 82(1):197-206; discussion 206-207.
  12. Department of Health and Human Services (DHHS), National Institutes of Health (NIH) and the National Heart, Lung, and Blood Institute (NHLBI). National Emphysema Treatment Trial (NETT): Evaluation of lung volume reduction surgery for emphysema. May 20, 2003. Available at: http://www.nhlbi.nih.gov/health/prof/lung/nett/lvrsweb.htm. Accessed on March 16, 2017.
  13. Fein AM, Branman SS, Casaburi R, et al. Lung volume reduction surgery: Official statement of the American Thoracic Society. Am J Respir Crit Care Med. 1996; 154(4 Pt 1):1151-1152.
  14. Global Initiative for Chronic Obstructive Lung Disease (GOLD), World Health Organization (WHO), National Heart, Lung and Blood Institute (NHLBI). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Bethesda, MD: NHLBI; 2005. Updated February 2016.
  15. Martinez FJ, Foster G, Curtis JL, et al.; NETT Research Group. Predictors of mortality in patients with emphysema and severe airflow obstruction. Am J Respir Crit Care Med. 2006; 173(12):1326-1334.
  16. Naunheim KS, Wood DE, Krasna MJ, et al.; National Emphysema Treatment Trial Research Group (NETT). Predictors of operative mortality and cardiopulmonary morbidity in the National Emphysema Treatment Trial. J Thorac Cardiovasc Surg. 2006a; 131(1):43-53.
  17. 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 (NETT). Ann Thorac Surg. 2006b; 82(2):431-443.
  18. Shah PL, Slebos DJ, Cardoso PF, et al. Bronchoscopic lung-volume reduction with Exhale airway stents for emphysema (EASE trial): randomised, sham-controlled, multicentre trial. Lancet. 2011; 378(9795):997-1005. NCT00391612.
  19. Snyder ML, Goss CH, Neradilek B, et al.; National Emphysema Treatment Trial Research Group (NETT). Changes in arterial oxygenation and self-reported oxygen use after lung volume reduction surgery. Am J Respir Crit Care Med. 2008; 178(4):339-345.
  20. Stoller JK, Gildea TR, Ries AL, et al.; National Emphysema Treatment Trial Research Group (NETT). Lung volume reduction surgery in patients with emphysema and alpha-1 antitrypsin deficiency. Ann Thorac Surg. 2007; 83(1):241-251.
  21. van Agteren JE, Carson KV, Tiong LU, Smith BJ. Lung volume reduction surgery for diffuse emphysema. Cochrane Database Syst Rev. 2016; (10):CD001001.
  22. Washko GR, Fan VS, Ramsey SD, et al.; National Emphysema Treatment Trial Research Group (NETT). The effect of lung volume reduction surgery on chronic obstructive pulmonary disease exacerbations. Am J Respir Crit Care Med. 2008; 177(2):164-169.
Websites for Additional Information
  1. American Lung Association: Emphysema. Available at: http://www.lungusa.org/lung-disease/emphysema/. Accessed on March 16, 2017.
  2. National Institutes of Health. National Heart, Lung, and Blood Institutes. Lung Diseases Information. Available at: http://www.nhlbi.nih.gov/health/public/lung/index.htm. Accessed on March 16, 2017.
  3. National Library of Medicine. MedlinePlus. COPD (Chronic Obstructive Pulmonary Disease). Available at: http://www.nlm.nih.gov/medlineplus/copdchronicobstructivepulmonarydisease.html. Accessed on March 16, 2017.
Index

Chronic Obstructive Pulmonary Disease (COPD)
Emphysema
Lung Volume Reduction Surgery
Reduction Pneumoplasty

Document History

Status

Date

Action

Reviewed 05/04/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated the formatting in the Position Statement section. The Rationale and References sections were updated.
Reviewed 05/05/2016 MPTAC review. References were updated. Removed ICD-9 codes from Coding section.
Reviewed 05/07/2015 MPTAC review. The Rationale and References were updated.
Reviewed 05/15/2014 MPTAC review. References were updated.
Reviewed 05/09/2013 MPTAC review. The Rationale and References were updated.
Reviewed 05/10/2012 MPTAC review. The Rationale and References were updated.
  01/01/2012 Updated Coding section with 01/01/2012 CPT changes.
Reviewed 05/19/2011 MPTAC review. Format updates to Position Statements without revisions to current criteria. Rationale, Definitions, and References were updated.
Reviewed 05/13/2010 MPTAC review. Rationale and References were updated.
Reviewed 05/21/2009 MPTAC review. References were updated.
Reviewed 05/15/2008 MPTAC review. References were updated.
  02/21/2008 The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed 05/17/2007 MPTAC review. References and Coding Sections were updated.
Revised 06/08/2006 MPTAC review. Addition of the term, "bilateral" to the position statement regarding emphysema for clarification; also the required presurgical time period for abstinence from smoking was changed to a 4 month minimum, consistent with the NETT protocols. References were updated.
  11/21/2005 Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised 07/14/2005 MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

04/28/2005

SURG.00022 Lung Volume Reduction Surgery
WellPoint Health Networks, Inc.

04/28/2005

3.05.01 Lung Reduction