BlueCross BlueShield of Tennessee Medical Policy Manual

Respiratory

• Actigraphy for Sleep Disorders

• Bullectomy

• Carbogen (95% Oxygen, 5% Carbon Dioxide) Inhalation in Cancer Treatment

• Drug-Eluting Lung Stents for Emphysema

• Electrophrenic Pacemaker

• Extracorporeal Membrane Oxygenation (ECMO)

• Home Pulse Oximetry

• Home Spirometry

• Hyperbaric Oxygen Pressurization / Therapy (HBO2)

• Laser Assisted Uvulopalatoplasty (LAUP)

• Lung and Lobar Transplantation

• Lung Volume Reduction Surgery (LVRS)

• Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders

• Mechanical In-Exsufflator (Cough Machine)

• Nebulizer Use in Home (Adult & Pediatric)

• Oral Appliances for Management of Mild to Moderate Obstructive Sleep Apnea (OSA)

• Outpatient Pulmonary Rehabilitation

• Palatal Implants for the Treatment of Obstructive Sleep Apnea or Snoring

• Percussion Devices for the Treatment of Respiratory Conditions

• Positron Emission Tomography (PET) for Miscellaneous Applications

• Radiofrequency Tissue Volume Reduction (RFTVR) for the Treatment of Upper Airway Obstruction

• Rhinomanometry and Acoustic Rhinometry

• Sleep Disorder Studies

• Uvulopalatopharyngoplasty (UPPP)/Palatopharyngoplasty (PPP)

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