1.0 CPT CODES
30000 - 32488, 32491, 32500
- 32999, 64568 - 64570, 96570, 96571, 0466T - 0468T
2.0 HCPCS
Codes
C1767,
C1778, C1787
3.0 DESCRIPTION
The respiratory system is comprised
of the tubular and cavernous organs and structures by means of which pulmonary
ventilation and gas exchange between ambient air and the blood are
brought about.
4.0 POLICY
4.1 Services
and supplies required in the diagnosis and treatment of illness
or injury involving the respiratory system are covered.
4.2 Resection of pneumatoceles
is a covered procedure.
4.3 Lung Volume
Reduction Surgery (LVRS) is a covered procedure, see
Section 8.2.
4.4 Endoscopic thoracic sympathectomy
(Current Procedural Terminology (CPT) code 32664) is covered for treatment
of severe primary hyperhidrosis when appropriate nonsurgical therapies
have failed and the hyperhidrosis results in significant functional
impairment.
4.5 Implantable
Hypoglossal Nerve Stimulation (HGNS) (CPT codes 64568 and 0466T)
for the treatment of moderate-to-severe Obstructive Sleep Apnea
(OSA) is covered in accordance with United States (US) Food and Drug
Administration (FDA) labeled indications.
5.0 Exclusions
5.1 Pillar
palatal implant system for the treatment of OSA is unproven.
5.2 Uvulopalatopharyngoplasty (UPPP)
(CPT code 42145) for the treatment of Upper Airway Resistance Syndrome
(UARS) is unproven).
5.3 Nitric
oxide expired gas determination (CPT code 95012) for asthma is unproven.
5.4 Bronchial Thermoplasty (BT)
(CPT codes 31660 and 31661) for the treatment of asthma is unproven.
5.5 Radiofrequency Ablation (RFA)
of the tongue base to treat OSA is unproven.
6.0 Effective Dates
6.1 December
1, 2006, for endoscopic thoracic sympathectomy for severe primary
hyperhidrosis.
6.2 August
15, 2019, for HGNS for the treatment of moderate-to-severe OSA.