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TRICARE Policy Manual 6010.60-M, April 1, 2015
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.
Revision:  C-107, January 6, 2023
30000 - 32488, 32491, 32500 - 32999, 64568 - 64570, 64582 - 64584, 96570, 96571, 0467T, 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) procedure 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 64568 and 64582 - 64584) for the treatment of moderate-to-severe Obstructive Sleep Apnea (OSA) is covered in accordance with U.S. 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 procedure code 42145) for the treatment of Upper Airway Resistance Syndrome (UARS) is unproven).
5.3  Nitric oxide expired gas determination (CPT procedure code 95012) for asthma is unproven.
5.4  Bronchial Thermoplasty (BT) (CPT procedure codes 31660 and 31661) for the treatment of asthma is unproven.
5.5  Radiofrequency Ablation (RFA) of the tongue base to treat Obstructive Sleep Apnea (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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