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Coverage criteria policies

Bronchial thermoplasty

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for bronchial thermoplasty.

Coverage

Bronchial thermoplasty is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered
  1. The ordering physician is a pulmonologist;
  2. Candidates should have a documented diagnosis of severe asthma and be 18 years or older;
  3. Asthma is not well controlled on inhaled corticosteroids and long acting beta2-agonists as evidenced by:
    1. An Asthma Control Test (ACT) score 19 or less and/or
    2. Risk Assessment Total of 1 or more.
  4. Candidates should
    1. Be able to undergo bronchoscopy per hospital guidelines;
    2. Have no pacemaker, internal defibrillator, or implantable electronic devices;
    3. Have no known coagulopathy;
    4. Have no known sensitivity to medications required to perform bronchoscopy;
    5. Have not had previous treatment with the Alair® System in the area to be treated; and
    6. Have no known unstable co-morbid conditions that would present a risk for bronchoscopy.

Definitions

Bronchial thermoplasty is a non-drug approach to treat patients with severe asthma. During Bronchial Thermoplasty, the Alair® catheter is introduced under direct visualization through the working channel of a flexible bronchoscope. Thermal energy heats the airway smooth muscle to inhibit smooth muscle contraction in all airways reachable by the bronchoscope. The procedure is done on an outpatient basis under conscious sedation, and three sessions are typically required.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes require prior authorization:

Codes

Description

31660

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe

31661

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial

thermoplasty, 2 or more lobes

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Castro, M., Rubin, A. S., Lviolette, M., Fiterman, J., Lima, M. D. A., Shah, P. L., et al. (2010). Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial. American Journal of Respiratory and Critical Care Medicine, Vol. 181(2), 116–124. doi: 10.1164/rccm.200903-0354OC.
  2. Castro, M., Rubin, A., Laviolette, M., Hanania, N. A., Armstrong, B., Cox, G. (2011). Persistence of effectiveness of bronchial thermoplasty in patients with severe asthma. Annals of Allergy, Asthma & Immunology, Vol. 107(1), 65-70. doi:10.1016/j.anai.2011.03.005.
  3. Chung, K. F., Wenzel, S. E., Brozek, J. L., Bush, A., Castro, M., Sterk, P. J., et al. (2014). International ERS (European Respiratory Society) / ATS (American Thoracic Soceity) guidelines on definition, evaluation and treatment of severe asthma. European Respiratory Journal, Vol. 43, 343-373. doi: 10.1183/09031936.00202013.
  4. Cox, G., Miller, J. D., McWilliams, A., FitzGerald, J. M., Lam, S. (2006). Bronchial thermoplasty for asthma. American Journal of Respiratory and Critical Care Medicine. Vol. 173(9), 965-969. doi: 10.1164/rccm.200507-1162OC.
  5. Cox, G., Thomson, N. C., Rubin, A. S., Niven, R. M., Corris, P. A., Siersted, H. C., et al. (2007). Asthma control during the year after bronchial thermoplasty. New England Journal of Medicine, Vol. 356(13), 1327-1337.
  6. ECRI Institute. (2013). Bronchial thermoplasty for treating adult patients with severe persistent asthma. Plymouth Meeting, PA: ECRI Institute.
  7. Global Initiative for Asthma (2016). Global strategy for asthma management and prevention. Available from: www.ginasthma.org.
  8. Hayes, Inc. (2016). Bronchial thermoplasty for treatment of asthma. Philadelphia, PA: Hayes, Inc.
  9. NICE (2012). Bronchial thermoplasty for severe asthma. NICE clinical guideline. Available at nice.org.uk/guidance/ipg419.
  10. Pavord, I. D., Cox, G., Thomson, N. C., Rubin, A. S., Corris, P. A., Niven, R. M., et al. (2007). Safety and efficacy of bronchial thermoplasty in symptomatic, severe asthma. American Journal of Respiratory and Critical Care Medicine. Vol. 176, 1185-1191. doi: 10.1164/rccm.200704-571OC.
  11. Pavord, I. D., Thomson, N. C., Niven, R. M., Corris, P. A., Chung, K. F., Cox, G., et al. (2013). Safety of bronchial thermoplasty in patients with severe refractory asthma. Annals of Allergy, Asthma & Immunology, Vol. 111, 402-407. doi: dx.doi.org/10.1016/j.anai.2013.05.002.
  12. Thomson, N. C., Rubin, A. S., Niven, R. M., Corris, P. A., Siersted, H. C., Olivenstein, R., et al. (2011). Long-term (5 year) safety of bronchial thermoplasty: asthma intervention research (AIR) trial. BMC Pulmonary Medicine, Vol. 11(8), 1-9. doi:10.1186/1471-2466-11-8.
  13. Wechsler, M. E., Laviolette, M., Rubin, A. S., Fiterman, J., Lapa e Silva, J. R., Shah, P. L., et al. (2013). Bronchial thermoplasty: long-term safety and effectiveness in patients with severe persistent asthma. Journal of Allergy and Clinical Immunology, Vol. 132, 1295-1302. doi: dx.doi.org/10.1016/j.jaci.2013.08.009.
  14. Wilhelm, C. P., Chipps, B. E. (2015). Bronchial thermoplasty: a review of the evidence. Annals of Allergy, Asthma & Immunology, Vol. 116, 92-98. doi: dx.doi.org/10.1016/j.anai.2015.11.002.

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Policy activity

  • 05/17/2010 - Date of origin
  • 05/17/2010 - Effective date
Review date
  • 10/2016

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