Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for navigational bronchoscopy (CPT 31627). Pickering and colleagues explain that while the concept of navigation bronchoscopy is not new, it has evolved over past few decades and is utilized for diagnostic sampling of lung and mediastinal lesions, placement of fiducial markers, or dye marking of the overlying pleura. The authors further note that the diagnostic yield using this technology is superior to conventional bronchoscopy techniques. Ashraf and colleagues report that infections remain a common cause of lung nodules, masses, and cavities and that electromagnetic navigation bronchoscopy dramatically improves on the diagnostic yield of peripheral lesions, especially of small lesions. The authors note that while its role in infection is less defined, it has value especially in the diagnosis of fungal and mycobacterial infections and in cavitating lesions. Electromagnetic navigation bronchoscopy may be used in patients who require lung biopsy for diagnosis but have a high risk of complication from other invasive diagnostic procedures and safely allows for biopsies and sampling from several areas and lesions to help maximize the likelihood of identifying the multiple possible etiologies of the lesions. In this case, as the patient has leukemia, is on immunosuppression, and has a history of pulmonary aspergillosis, he at risk of both malignant and infectious diseases of multiple etiologies, including recurrent aspergillosis. Computed tomography (CT) of the chest showed an increase in peripheral lesions and a new left lower lobe solid pulmonary nodule. He has leukemia, is on immunosuppression, and has had pulmonary aspergillosis in the past, so he at risk of both malignant and infectious diseases of multiple etiologies, including recurrent aspergillosis. In this clinical setting, the patient is a high risk for mortality if he were to develop a complication such as pneumothorax, hemothorax, or bleeding due to his diffuse and extensive lung disease and may require multiple biopsies from different parts of the lungs as his diffuse lung disease appears to correspond to different pathologies. Therefore, navigational bronchoscopy (CPT 31627) is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested navigational bronchoscopy (CPT 31627) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with sub-specialty certifications in pulmonary disease and in critical care medicine and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.