Lung Volume Reduction Surgery for Severe Emphysema
DESCRIPTION
Lung volume reduction surgery (LVRS) is proposed as a treatment option for individuals with severe emphysema who have failed optimal medical management. The procedure involves the excision of diseased lung tissue and aims to reduce symptoms and improve quality of life.
Lung volume reduction is a surgical treatment for individuals with severe 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 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 purported to correct ventilation perfusion mismatch and improve right ventricular filling.
Lung volume reduction surgery is intended to be palliative not curative. The procedure is designed to relieve dyspnea and improve functional capacity and quality of life. Individuals continue to have severe emphysema, and most will show further progression of their disease over time. It is also hoped that LVRS may extend survival time.
POLICY
Lung volume reduction surgery for severe emphysema is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Lung volume reduction surgery for all other conditions is considered investigational.
MEDICAL APPROPRIATENESS
Lung volume reduction surgery for severe emphysema is considered medically appropriate if ALL the following criteria are met:
Predominantly upper lobe emphysema with hyperinflation and heterogeneity (i.e., target areas for removal)
Forced expiratory volume in one second (FEV-1) when ANY ONE of the following criteria are met:
For an individual younger than 70 years of age, the FEV-1 must be no more than 45% of the predicted value
For an individual 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
Age younger than 75 years
Acceptable nutrition status(i.e., 70-130% of ideal body weight)
ALL the following criteria:
Ability to participate in a vigorous pulmonary rehabilitation program
Post-rehabilitation 6-minute walk of at least 140 meters
Able to complete 3 minute unloaded pedaling in exercise tolerance test
No coexisting major medical problems that would significantly increase operative risk
Willingness to undertake risk of morbidity and mortality associated with LVRS
Abstinence from cigarette smoking for at least 4 months
PaO2 on room air greater than or equal to 45 mm Hg (greater than or equal to 30 mm Hg at elevations of 5,000 feet or higher)
PaCO2 on room air less than or equal to 60 mm Hg (less than or equal to 55 mm Hg at elevations of 5,000 feet or higher)
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Well-designed studies in peer-reviewed journals are not available regarding the use of lung volume reduction surgery for conditions other than severe emphysema. Therefore, health care outcomes can’t be measured for these other conditions.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (6:2011). Lung volume reduction surgery for severe emphysema (7.01.71). Retrieved August 15, 2011 from BlueWeb. (11 articles and/or guidelines reviewed)
Complete Guide To Medicare Coverage Issues [Computer software]. (2011, April). Lung volume reduction surgery (reduction pneumoplasty) (NDC 240-1, p. 2-196 - 2-198). Ingenix.
Fishman, A., Martinez, F., Naunheim, K., Piantadosi, & S., Wise. (2003). A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. The New England Journal of Medicine, 348 (21), 2059-2073.
Ginsburg, M. E., Thomashow, B. M., Yip, C. K., DiMango, A. M., Maxfield, R. A., et al. (2011). Lung volume reduction surgery using the NETT selection criteria. Annals of Thoracic Surgery, 91 (5), 1556-1561.
Miller, J. D., Berger, R. L., Malthaner, R. A., Celli, B. R., Goldsmith, C. H., Ingenito, E. P., et al. (2005). Lung volume reduction surgery vs medical treatment: for patients with advanced emphysema. Chest, 127 (4), 1166-1177.
National Institutes of Health. (2003, May). National emphysema treatment trial (NETT): Evaluation of lung volume reduction surgery for emphysema. Retrieved May 17, 2005 from http://www.nhlbi.nih.gov/health/prof/lung/nett/lvrsweb.htm.
Sanchez, P. G., Kucharczuk., J. C., Su, S., Kaiser, L. R., & Cooper, J. D. (2010). National Emphysema Treatment Trial redux: Accentuating the positive. General Thoracic and Cardiovascular Surgery, 140 (3), 564-572.
The Technology Evaluation Center. (2003, December). Lung volume reduction surgery for severe emphysema (Vol. 18, No. 17). Chicago: BlueCross BlueShield Association. (50 articles and/or guidelines reviewed)
ORIGINAL EFFECTIVE DATE: 3/1996
MOST RECENT REVIEW DATE: 10/17/2011
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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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