Coverage Policy Manual
Policy #: 2000005
Category: Surgery
Initiated: February 2000
Last Review: October 2018
  Lung Volume Reduction Surgery (LVRS)

Description:
Lung volume reduction surgery (LVRS) is proposed as a treatment option for patients with severe emphysema who have failed optimal medical management. The procedure involves the excision of diseased lung tissue and aims to reduce symptoms and improve quality of life.
 
Lung volume reduction is a surgical treatment for patients with severe emphysema involving the excision of peripheral emphysematous lung tissue, generally from both upper lobes. The precise mechanism of clinical improvement for patients undergoing lung reduction surgery has not been firmly established. However, it is believed that elastic recoil and diaphragmatic function are improved by reducing the volume of diseased lung. In addition to changes in chest wall and respiratory mechanics, the surgery is purported to correct ventilation perfusion mismatch and improve right ventricular filling.
 
Research on LVRS has focused on defining the sub-group of patients most likely to benefit from the procedure. It appears that strict selection criteria and extensive technical experience with the procedure significantly influence results. Potential benefits of the procedure e.g., improvement in functional capacity and quality of life must be weighed against the potential risk of the procedure e.g., risk of post-operative mortality.
 
Coding
In January 2012, a specific CPT code was added to be used for LVRS:
 
CPT 32672-Thoracoscopy, surgical; with resection-plication for emphysematous lung (bullous or non-bullous) for lung volume reduction (LVRS), unilateral includes any pleural procedure, when performed.
 
Although the new CPT code is a unilateral code, it would be expected that LVRS would be done bilaterally because the National Emphysema Therapy Trial (which determined the effectiveness of LVRS) assessed LVRS performed bilaterally in patients with advanced bilateral emphysema (McKenna, 2004).
 

Policy/
Coverage:
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Lung volume reduction surgery for treatment of dyspnea secondary to severe emphysema meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
Note: Since the National Emphysema Therapy Trial assessed LVRS bilaterally, it would be expected that for CPT 32672 to be covered, the procedure would be performed bilaterally either on the same date of service or within 7-10 days of the initial procedure.
 
Note: Health insurance regulation prohibits an insurer from directing a member to a specific provider for health care services (although the law does allow a differential in payment for the service depending on whether the member has a contract that includes “in-network” versus “out-of-network” coverage).  ABCBS strongly recommends that any member considering LVRS should consider having the surgery at a facility, and by surgeons, highly experienced in this surgery.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Lung volume reduction surgery for any other indication does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For members with contracts without primary coverage criteria, lung volume reduction surgery is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 

Rationale:
    • Improvements in pulmonary function have been assumed to be surrogate markers for overall improvements in health, including quality of life. However, this assumption has been challenged by several authors who suggest that lung function measurements only partially reflect the ongoing pathological process and thus may not reflect the complete state of the disease or its effect on exercise capacity or quality of life. For example, there is only a weak to modest correlation between dyspnea and pulmonary function parameters. FEV-1 (forced expiratory volume in 1 second) is considered the critical measure of pulmonary function. However, whether the reported improvement in FEV-1 resulting from lung volume reduction surgery is associated with any improvement in overall survival has not been demonstrated to date and will require longer term data to answer.
    • The major objective of lung volume reduction surgery is the improvement of health-related quality of life, yet few studies have attempted to measure the outcome directly. Exercise tolerance tests, such as the commonly used 6-minute walk test, have been assumed to reflect quality of life. However, measures of exercise capacity correlate only weakly or moderately with quality of life instruments and do not necessarily reflect functional ability in the activities of daily living that affect quality of life.
    • The National Heart, Lung, and Blood Institute (NHLBI) and Health Care Financing Administration (HCFA) jointly sponsored the National Emphysema Treatment Trial (NETT), which focused on improvement in overall survival as the primary outcome of interest. This contrasts with the intermediate outcome of improved pulmonary function. The recruitment goal of the trial is 4,700 patients.
    • Based on a review of the published literature focusing on final health outcomes, the policy concluded that there was insufficient evidence to permit conclusion concerning the effect of lung volume reduction surgery. Deficiencies in the published data included the lack of carefully structured and controlled clinical studies, inconsistent use of pre- and postoperative pulmonary rehabilitation, high percentage of treated patients whose outcomes were not assessed in the postoperative follow-up period, and finally the above-discussed paucity of data on final health outcomes.
 
2001 Update
There have been several reports on the preliminary outcomes of the NETT trial. The NETT trial research group compared the results of 69 patients with severe lung disease (defined as an FEV-1 less than 20% predicted and a homogeneous distribution of emphysema or a carbon monoxide diffusing capacity less than 20% predicted) with the results of 70 similarly selected but medically treated patients.  In this group of high risk patients, the surgical mortality was 16% compared to 0% in the medically treated patients. The authors conclude by saying that high risk patients are unlikely to benefit from the surgery. Geddes and colleagues reported on the results of a smaller randomized trial of 48 patients.   There were 5 deaths in the surgical group (21%) compared to 3 in the medical group (12%). At 6 months, functional measures and quality of life measures improved in the surgical group. However, no conclusions could be drawn regarding mortality. It should be noted that unlike the NETT trial, this trial excluded patients with severe emphysema.  There is no change to the policy statement.
 
2011 Update
The policy was updated with a search of the MEDLINE database from October 2004 through August 2011.  A follow-up analysis of data from NETT was published; there was a median follow-up of 4.3 years compared to 2.4 years in the initial full report (Naunheim, 2006). Patient recruitment took place between January 1998 and July 2002; 70% of randomized patients participated in the extension of follow-up conducted in 2003, and 76% participated in the mailed quality-of-life data collection in 2004. The analysis was done on an intention-to-treat basis including all 1,218 randomized patients. During follow-up, 46.5% (283/608) patients in the lung volume reduction surgery (LVRS) group and 53.1% (324/610) patients in the medical therapy group died. The overall mortality rate in the LVRS group was significantly lower (0.11 per person-year) than the rate in the medical therapy group (0.13 per person-year, relative risk [RR]: 0.85, p=0.02). In the group as a whole, a greater proportion of patients in the LVRS group had higher exercise capacity (defined as an increase of more than 10 watts) after 3 years compared to those in the medical therapy group; 9% versus 1%, respectively (p<0.001). Moreover, more patients in the LVRS group experienced a clinically significant improvement in health-related quality of life (>8 unit decrease in the SGRQ) at 3, 4, and 5 years than in the medical therapy group. These differences were statistically significant at 3 years (20% vs. 8%) and 4 years (10% vs. 4% - both respectively).
 
Data analyses were also conducted by predefined subgroups of patients categorized by upper-lobe predominance (yes vs. no) combined with exercise capacity (high vs. low). Findings for these subgroups during the first 24 months of the study are described above. In the group with predominately upper lobe emphysema and low exercise capacity, the initial report found mortality to be significantly lower in the LVRS group. The mortality advantage continued after a mean of 4.3 years of follow-up (RR: 0.57, p=0.01). In this subgroup (n=290), compared to medical therapy, those in the LVRS group were also more likely to have an improvement in exercise capacity throughout 3 years of follow-up testing (p<0.01) and to have an 8-point improvement in quality of life through 4 years of follow-up testing (p=0.003). In the long-term follow-up study, there was not a significant difference in the mortality rate between the LVRS and medical therapy groups in any of the 3 other subgroups. However, in the subgroup with predominately upper lobe emphysema and high exercise capacity (n=419), there was a significantly higher improvement in exercise capacity over 3 years (p<001) and quality of life over 4 years (p=0.003 in year 4) in the LVRS compared to the medical therapy group. For example, at 3 years, 10% of the 117 patients assessed in the LVRS group and 2% of the 141 patients assessed in the medical therapy group had improvement in exercise capacity compared to their post-rehabilitation baseline score. Moreover, at 4 years, 17% of 95 patients assessed in the LVRS group and 4% of 118 patients assessed in the medical therapy group had an improvement of greater than 8 in the SGRQ compared to their post-rehabilitation baseline score. At 3 years, patients with non-upper lobe emphysema, and either high or low exercise capacity, did not have significantly different exercise capacity or quality-of-life outcomes in the LVRS compared to medical therapy groups. These long-term data confirm the initial findings from NETT that LVRS offers a survival advantage to patients with predominately upper lobe emphysema and low exercise capacity, offers symptom improvement in patients with upper lobe emphysema and high exercise capacity and that patients with non-upper lobe emphysema are unlikely to benefit from the procedure. A limitation of the long-term follow-up study was that fewer than 80% of surviving NETT participants took part in the study extension.
 
The Cochrane collaboration published a systematic review and meta-analysis of randomized, controlled trials (RCTs) for diffuse emphysema (Tiong, 2006). The review included a total of 8 studies; however, 1 study, NETT, accounted for 73% of patients, which limits the usefulness of the findings of the meta-analysis. Two of the trials were published after the previous policy update in 2004 and are summarized below:
 
Hillerdal and colleagues conducted a multicenter study in Sweden evaluating LVRS that was published in 2005 (Hillerdal, 2005). Eligibility criteria included age 75 years or younger, forced expiratory volume in one second (FEV-1) of no more than 35% of predicted normal value; excessive hyperinflation with a residual volume of at least 200% of predicted, with radiologic signs of emphysema and decreased mobility of the diaphragm. Because of the researchers’ clinical experience that preoperative exercise training improves postoperative outcomes, they required all individuals to successfully complete a 6-week physical training program. The program consisted of 2 sessions per week with a physical therapist and a home exercise program. Of the 114 patients eligible for the initial training (of 304 evaluated), 3 were unable to complete the program, and 5 died before completion; the remaining 106 patients were randomized to continued physical training alone (n=53) or LVRS plus continued physical training for 3 months post-surgery (n=53). A total of 42 (79%) patients in the surgery group and 43 (81%) in the physical training group were followed for 1 year; intention-to-treat analysis was used. The primary outcome was health status according to the Swedish version of the Short-Form General Health Survey (SF)-36 instrument and the disease-specific SGRQ. Both instruments have scores ranging from 0 to 100; in the SF-36, 100 represents the best health status and in the SGRQ, 100 represents poor health status. For both instruments, the minimally important clinical difference was defined as 4 scale points. In an analysis adjusting for age and sex, there was a significant difference in the score on the SGRQ at 6 months (mean difference of 14.3 points) and 12 months (mean difference of 14.7 points), favoring the LVRS group. The total score on the SF-36 at follow-up was not reported. At 12 months, there was significantly more improvement in 6 of the 8 SF-36 subscales in the LVRS group compared to the physical training group. The researchers only reported mean difference in the scales, not the proportion of patients who achieved a certain level of improvement. Mortality was a secondary outcome. There were 7 deaths in the LVRS group (13%) and 2 deaths in the physical training group (4%); this difference was not statistically significant (p=0.5), but the study was likely underpowered for this outcome. Six of the deaths in the LVRS group were caused by respiratory failure and pneumonia; the seventh patient died suddenly at home. Respiratory failure was also the cause of the 2 deaths in the physical training group. The authors point out that the baseline SGRQ scores were lower than in the NETT (59 versus 53, respectively), suggesting a more severely impaired population. The current study did not examine patient outcomes according to upper-lobe predominance or initial exercise capacity.
 
In 2006, Miller and colleagues published a study with data from 5 centers in Canada (Miller, 2006). Eligibility criteria included: age between 40 and 79 years; disabling dyspnea; FEV-1 of no more than 40% of predicted; diffusing capacity no more than 60%; and total lung capacity no more than 120% or residual volume no less than 200%. After eligibility screening, medical therapy was optimized and then patients were randomized to LVRS (n=32) or continued medical therapy (n=30). The researchers had originally planned to enroll 350 individuals but, due to the low proportion of screened individuals who were eligible, they stopped recruitment when only 18% of their target was met (467 individuals were screened to identify 62 who were eligible). Thus, the study may have been underpowered to detect differences in outcomes between groups. None of the randomized patients were lost to follow-up, and analysis was intention to treat. The overall 2-year survival rate was similar in the two groups; there were 5/32 (16%) deaths in the LVRS group and 4/30 (13%) deaths in the medical therapy group (p=0.935). At 3 and 6 months, there was a significantly higher change from baseline in FEV-1 in the LVRS group compared to the medical therapy group, but there was a non-significant difference between groups in FEV-1 at 12 and 24 months. The mean difference in FEV-1 at 24 months was 0.06 liters.
 
Sanchez and colleagues published an analysis of data from the National Emphysema Treatment Trial, focusing on patients who had upper lobe predominance and a heterogenous distribution of emphysema (factors associated with a positive outcome) (Sanchez, 2010). This analysis considered both factors; patients needed to meet NETT criteria for upper lobe predominant disease and to have heterogenous distribution of disease defined as a difference in severity of emphysema in any 2 zones of the lung of at least 2 points on a 0-to-4 severity scale. Of the 1,218 patients enrolled in the study, 511 patients (42%) met inclusion criteria; 261 were in the LVRS group, and 250 were in the medical therapy group. The median follow-up was 4.3 years. Using Kaplan-Meier analysis, the 3-year survival rate was 81% in the LVRS group and 74% for the medical group, p=0.05. At 5 years, the estimated survival rate was significantly higher in the LVRS group than the medical therapy group, 70% versus 60%, p=0.02. Maximal exercise capacity, another NETT primary outcome, was a mean of 49 watts in the LVRS group and 38 watts in the medical therapy group at 1 year, p<0.001. At 3 years, the values in the two groups were 43 and 38 watts, respectively, and the between-group difference was not statistically significant.
 
A retrospective case series was identified where 49 patients treated at a single institution in the United States were selected for bilateral lung volume reduction surgery using NETT inclusion and exclusion criteria (Ginsburg, 2011). There was no operative, postoperative, or 90-day mortality. The most common complication was prolonged air leaks (>7 days), which occurred in 21 (43%) of patients. Other complications, each experienced by no more than 2 patients, included respiratory failure, pneumonia, deep vein thrombosis (DVT), and delirium. One patient was readmitted to the hospital and one underwent reoperation. The Kaplan-Meier estimate of survival was 98% (95% confidence interval [CI]: 94-100%) at 1 year and 95% (95% CI: 88-100%) at 3 years. The mean FEV-1 increased from 25% of predicted at baseline to 36% of predicted at 1 year (p<0.0001).
 
Summary
Findings from the National Emphysema Treatment Trial (NETT), a multicenter randomized, controlled trial, suggest that lung-volume reduction surgery is effective at reducing mortality and improving quality of life in selected patients with severe emphysema.
 
2012 Update
A literature search conducted through September 2012 did not reveal any new information that would prompt a change in the coverage statement.
 
2013 Update
A literature search was conducted using the MEDLINE database through September 2013.  No new information was identified that would prompt a change in the coverage statement. One observational study was identified.
 
In 2012, Baldi and colleagues conducted a retrospective analysis that included longer term follow-up than had been reported in the RCTs. The study included 52 emphysema patients who had lung volume reduction surgeries between 1993 and 2000 (Baldi, 2012). The 5-year survival rate was 73% and the 12-year survival rate was 20%. Eleven of 52 patients (21%) underwent lung transplantation a mean of 52 months after LVRS. In a multivariate model, 2 variables were statistically associated with patient survival. These were preoperative pulmonary arterial pressure (hazard ratio [HR]: 2.11, 95% CI: 0.99 to 4.45) and upper lobe distribution of emphysema (HR: 2.43, 95% CI: 1.10 to 5.36).
 
2014 Update
A literature search conducted through September 2014 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
In 2013, Agzarian et al published long-term results of the CLVRS Trial (Agzarian, 2013). Fifty-two of 62 randomized patients (84%) were available for the long-term follow-up 8 to 10 years after treatment. One patient was excluded before surgery and 9 others were lost to follow-up. The proportion of patients surviving 5 and 10 years was 46% and 7%, respectively, in the LVRS group and 25% and 0% in the control group. According to Kaplan-Meier survival analysis, median survival was 63 months in the LVRS group and 47 months in the control group; the difference between groups was not statistically significant, p=0.20.
 
In 2014, Decker et al reviewed data on 538 patients from the Society of Thoracic Surgeons (STS) Database who received LVRS, and compared these data with those of the 608 NETT participants randomized to the surgery group (Decker, 2014). None of the patients in the STS database had an FEV1 less than 20% of predicted or a carbon monoxide diffusing capacity less than 20% of predicted; thus, these patients would not have been considered high risk in NETT. However, about 10% of patients in the STS database had previous cardiothoracic surgery and 1.5% had lung cancer, and these would have been exclusion criteria in NETT. Overall, the mortality rate within 30 days of LVRS was not significantly different in the STS database compared with NETT (5.6% vs 3.6%, p=0.113). When database findings were compared with non-high-risk NETT participants, the 30-day mortality rate was significantly higher among patients in the STS database than NETT patients (5.6% vs 2.2%), p=0.005. This study was descriptive and did not attempt to propose patient selection criteria for LVRS.
 
2015 Update
A literature search conducted through September 2015 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
A 2014 study by Kaplan and colleagues reported on long-term outcomes in high-risk patients from the NETT trial (Kaplan, 2014). In this subgroup of 140 randomized patients, the mortality rate was higher in the LVRS group than the medical therapy group for the first 4.4 years but longer-term survival did not differ significantly in the 2 groups. Median survival was 2.14 years (95% CI: 1.20 to 4.07) in the LVRS group and 3.12 years (95% CI: 2.79 to 4.27) in the medical therapy group (p>0.05).
 
2016 Update
A literature search conducted through September 2016 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Clarenbach and colleagues reported an RCT in 30 patients scheduled for LVRS (Clarenbach, 2015).  The trial compared patients who were immediately treated with LVRS to patients who were treated after a 3-month waiting period. The primary outcomes were a physiologic measures (endothelial function) assessed by flow-mediated dilatation of the brachial artery at 3 months (2.9; 95% CI, 2.1 to 3.6; p<0.001) and C-reactive protein (p=NS). In the group treated with immediate LVRS, the secondary outcome of FEV1 improved by 29%. There were no significant differences between groups for the 6-minute walk test or levels of daily activity at 3 months. This trial included patients who had LVRS for either upper-lobe or lower-lobe disease, the latter being an indication not supported by the results of NETT.
 
Ongoing and Unpublished Clinical Trials
A search of ClinicalTrials.gov in September 2016 did not identify any ongoing or unpublished trials that would likely influence this review.
 
2017 Update
A literature search conducted through September 2017 did not reveal any new information that would prompt a change in the coverage statement.  The key identified literature is summarized below.
 
Huang and colleagues published pooled analyses and found a significantly higher odds or mortality in the medical therapy group than in LVRS at 3 months (odds ratio [OR], 5.16; 95% CI, 2.84 to 9.35) and no statistically significant difference between groups in mortality at 12 months (OR=1.05; 95% CI, .082 to 1.33) (Huang, 2011).
 
The 2016 Cochrane review is an update to the 2006 meta-analysis which included 8 RCTs published between 1999 and 2008 and gathered all available evidence from RCTs comparing the effectiveness of LVRS versus nonsurgical standard therapy in improving health outcomes for patients with severe diffuse Emphysema (van Agteren, 2016; Tiong, 2006).The search period for this update is September 2008 to April 2016. Two new trials contributing 89 participants (Clarenbach9 and Pompeo13) were identified and incorporated into the review as well as long-term follow-up data from the Canadian Lung Volume Reduction Surgery and NETT trials resulting in changes to the conclusions of this review as compared with 1999 and 2006 reviews.
 
A total of 11 studies (1760 participants) were included in the review. All studies were RCTs. The NETT study accounted for 68% of review participants. Short-term (90 days) and long-term (> 36 months) mortality and QOL were the primary outcomes evaluated. Secondary outcomes were FEV1 and 6-minute walk distance.
 
Reviewers confirmed prior findings of short-term mortality to be overall higher for LVRS than for control. Five studies could be evaluated for 90-day mortality, and the odds ratio for surgery versus control was 6.16 (95% CI, 3.22 to 11.79). However, long-term mortality calculated using the 2 added studies favored LVRS. The odds ratio for surgery versus control was 0.76 (95% CI, 0.61 to 0.95).
 
Statistically significant differences in QOL scores using the long-term follow-up studies data favored LVRS at the end of follow-up. Decreases on the SGRQ of -13.6 units (95% CI, -15.76 to -11.44) and -14.7 (95% CI, -19.65 to -9.75) are greater than the standard for the minimum clinically important reduction of 4 points for this questionnaire.
 
Pooled results from 5 of the review studies demonstrated improvements in FEV1 through the end of follow-up for LVRS. However, the percentages of participants contributing to the outcome decreased over time in both surgery and medical management groups due to the poor long-term prognosis for persons affected by chronic severe emphysema.
 
ONGOING AND UNPUBLISHED CLINICAL TRIALS
A search of ClinicalTrials.gov in September 2017 did not identify any ongoing or unpublished trials that would likely influence this review.
 
2018 Update
A literature search was conducted through September 2018.  There was no new information identified that would prompt a change in the coverage statement.  The key identified literature is summarized below.
 
PRACTICE GUIDELINES AND POSITION STATEMENTS
 
American Thoracic Society and European Respiratory Society
The American Thoracic Society and the European Respiratory Society published a joint statement on current research questions for chronic obstructive pulmonary disease (ATSERS, 2015). The statement discussed lung volume reduction surgery and asserted that, due to the significant complications from the procedure that may result in prolonged hospital stays and morbidity, additional studies would be needed to evaluate minimally invasive techniques that might reduce complications.

CPT/HCPCS:
32491Removal of lung, other than pneumonectomy; with resection-plication of emphysematous lung(s) (bullous or non-bullous) for lung volume reduction, sternal split or transthoracic approach, includes any pleural procedure, when performed
32672Thoracoscopy, surgical; with resection-plication for emphysematous lung (bullous or non-bullous) for lung volume reduction (LVRS), unilateral includes any pleural procedure, when performed

References: 1999 Blue Cross Blue Shield Association Technology Evaluation Center Assessment; Tab 1.

Agzarian J, Miller JD, Kosa SD et al.(2013) Long-term survival analysis of the Canadian Lung Volume Reduction Surgery trial. Ann Thorac Surg 2013; 96(4):1217-22.

Baldi S, Oliaro A, Tabbia G et al.(2012) Lung volume reduction surgery 10 years later. J Cardiovasc Surg (Torino) 2012; 53(6):809-15.

Celli BR, Decramer M, Wedzicha JA, et al.(2015) An official American Thoracic Society/European Respiratory Society statement: research questions in COPD. Eur Respir Rev. Jun 2015;24(136):159-172. PMID 26028628

Clarenbach CF, Sievi NA, Brock M, et al.(2015) Lung volume reduction surgery and improvement of endothelial function and blood pressure in patients with chronic obstructive pulmonary disease. a randomized controlled trial. Am J Respir Crit Care Med. Aug 1 2015;192(3):307-314. PMID 26016823

Decker MR, Leverson GE, Jaoude WA et al.(2014) Lung volume reduction surgery since the National Emphysema Treatment Trial: Study of Society of Thoracic Surgeons Database. J Thorac Cardiovasc Surg 2014.

Drazen JM.(2001) Surgery for emphysema - not for everyone. NEJM 2001; 345:1126-1128.

Fein AM, Branman SS, Casaburi R, et al.(1996) The American Thoracic Society has stated that the procedure is not investigational. Am J Respir Crit Care Med 1996; 154:1151-1152.

Geddes D, Davies M, Koyama H, et al.(2000) Effect of lung-volume-reduction surgery in patients with severe emphysema. NEJM 2000;343:239-45.

Gelb AF, McKenna RJ, Brenner M, et al.(1999) Lung function 4 years after lung volume reduction surgery for emphysema. Chest 1999; 116:1608-1615.

Ginsburg ME, Thomashow BM, Yip CK et al.(2011) Lung volume reduction surgery using the NETT selection criteria. Ann Thorac Surg 2011; 91(5):1556-61.

Hamacher J, Bloch KD, Stammberger U, et al.(1999) Two years' outcome of lung volume reduction surgery in different morphologic emphysema types. Ann Thor Surg 1999; 68:1792-1798.

Hillerdal G, Lofdahl CG, Strom K et al.(2005) Comparison of lung volume reduction surgery and physical training on health status and physiologic outcomes: a randomized controlled clinical trial. Chest 2005; 128(5):3489-99.

Holohan TV, Handelsman H.(1996) LVRS for end stage COPD. US Department Health and Human Services. Health Technology Assessment; #10; pp 1-30 1996.

Huang W, Wang WR, Deng B, et al.(2011) Several clinical interests regarding lung volume reduction surgery for severe emphysema: meta-analysis and systematic review of randomized controlled trials. J Cardiothorac Surg. 2011;6:148. PMID 22074613

Kaplan RM, Sun Q, Naunheim KS, et al.(2014) Long-term follow-up of high-risk patients in the National Emphysema Treatment Trial. Ann Thorac Surg. Nov 2014;98(5):1782-1789. PMID 25201722

Mckenna R.J JR, Benditt JO, DeCamp M, et al.(2004) Safety and efficacy of median sternotomy versus video-assisted thoracic surgery for lung volume reduction surgery. National Emphysema Treatment Trial Research Group. J Thor Cardiovasc Surg 2004;127:1350-60.

Miller JD, Malthaner RA, Goldsmith CH et al.(2006) A randomized clinical trial of lung volume reduction surgery versus best medical care for patients with advanced emphysema: a two-year study from Canada. Ann Thorac Surg 2006; 81(1):314-21.

National Emphysema Treatment Trial Research Group Patients at high risk of death after lung volume reduction surgery. NEJM 2001; 345:1075-83.

National Emphysema Treatment Trial Research Group.(2001) Patients at a high risk of death after lung-volume-reduction surgery. NEJM 2001; 345:1075-83.

National Treatment Trial Research Group.(2003) A randomized trial comparing lung volume reduction surgery with medical therapy for severe emphysema. NEJM 2003; 348:2059-2073.

Naunheim KS, Kaiser LR, Bavaria JE, et al.(1999) Long-term survival after thorascopic lung volume reduction: a multi-institutional review. Ann Thor Surg 1999; 68:2026-2031.

Naunheim KS, Wood DE, Mohsenifar Z et al.(2006) Long-term follow-up of patients receiving lung volume reduction surgery versus medical therapy for severe emphysema by the National Emphysema Treatment Trial research group. Ann Thorac Surg 2006; 82(2):431-43.

O'Brien GM, Furukawa S, Kuzma AM, et al.(1999) Improvements in lung function, exercise, and quality of life in hypercapnic COPD patients after lung volume reduction surgery. Department Med and Cardiothoracic Surg; Temple University School Med; Philadelphia; Chest; 1999; 115-75-84.

Pompeo E, Rogliani P, Tacconi F, et al.(2012) Randomized comparison of awake nonresectional versus nonawake resectional lung volume reduction surgery. J Thorac Cardiovasc Surg. Jan 2012;143(1):47-54, 54.e41. PMID 22056369

Sanchez PG, Kucharczuk JC, Su S et al.(2010) National Emphysema Treatment Trial redux: accentuating the positive. Gen Thorac Cardiovasc Surg 2010; 140(3):564-72.

Teschler H, Thompson AB, Stamatis G.(1999) Short- and long-term functional results after lung volume reduction surgery for severe emphysema. Eur Respiratory Journal 1999; 13:1170-1176.

Tiong LU, Davies R, Gibson PG, et al.(2006) Lung volume reduction surgery for diffuse emphysema. Cochrane Database Syst Rev. 2006(4):CD001001. PMID 17054132

Tiong LU, Gibson PG, Hensley MJ et al.(2006) Lung volume reduction surgery for diffuse emphysema. Cochrane Database Syst Rev 2006; (4):CD001001.

van Agteren JE, Carson KV, Tiong LU, et al.(2016) Lung volume reduction surgery for diffuse emphysema. Cochrane Database Syst Rev. Oct 14 2016;10:Cd001001. PMID 27739074

Ware, JH.(2003) The national emphysema treatment trial - how strong is the evidence. NEJM 2003; 348-2055-2057.

Young J, Fry-Smith A, Hyde C.(1999) Lung volume reduction surgery for chronic obstructive pulmonary disease with underlying severe emphysema. Thorax 1999; 54:779-889.

Yusen RD, Lefrak SS, Gierada DS, et al.(2003) A prospective evaluation of lung volume reduction surgery in 200 consecutive patients. Chest 2003; 123:1026-1037.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2019 American Medical Association.