3.0 POLICY
3.1 Pulmonary
services including pulmonary services provided as part of a treatment
program on an inpatient or outpatient basis are covered.
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.
3.3 Cryoablation for the
treatment of lung malignancies is proven effective July 11, 2023.
4.0 Exclusion
Oscillation and Lung Expansion
(OLE) combination devices, such as the Volara system, are unproven
for home use.