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TRICARE Policy Manual 6010.63-M, April 2021
Chapter 4
Section 8.1
Respiratory System
Issue Date:  August 26, 1985
Authority:  32 CFR 199.4(c)(2)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
30000 - 32488, 32491, 32500 - 32999, 64568 - 64570, 96570, 96571, 0466T - 0468T
2.0  HCPCS Codes
C1767, C1778, C1787
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.
4.1  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.
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