3.2 For an indication to be covered
the efficacy of the pulmonary services must be proven.
Note: Examples of proven indications
are: cardiopulmonary or pulmonary rehabilitation for pre- and post-lung
transplant patients when preauthorized by the appropriate preauthorizing
authority as outlined in the Policy on heart-lung and lung transplantation;
effective September 13, 1999, severe Chronic Obstructive Pulmonary
Disease (COPD) on an inpatient basis; and moderate and severe COPD on
an outpatient basis.