Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Pulmonary function tests (PFTs) can be performed in a variety of clinical situations.  PFTs, such as spirometry are routinely used for confirming or monitoring a diagnosis of asthma or COPD. 

2)    Specialized PFTs with known risks (challenge tests or stress tests) require prior authorization unless ordered or performed by a pulmonologist.

3)    There is no evidence supporting the routine use of PFTs for preoperative evaluation.

Pulmonary function tests include:

·         Spirometry,

·         Lung Volume,

·         Diffusion Capacity, 

·         Lung compliance,

·         Pulmonary Studies during Exercise Testing.

A. Simple spirometry is the mainstay of pulmonary function testing and is usually sufficient to differentiate between obstructive and restrictive disorders. It helps in evaluating obstructive lung diseases such as asthma and chronic obstructive pulmonary disease (COPD) for severity and response to therapy. Additional pulmonary function testing is usually not necessary for adequate clinical assessment.

B. Lung volume tests are most useful for assessing restrictive lung diseases such as those caused by scarring of lungs or by abnormalities in the ribcage or muscles of the chest wall.

C. Diffusion capacity is used to differentiate between chronic bronchitis, emphysema, and asthma in patient with obstructive patterns, and evaluate pulmonary involvement in systemic diseases (e.g., rheumatoid arthritis, systemic lupus).

D. Lung compliance testing is an invasive test. It is performed only when all other PFTs give equivocal results. It measures the elastic recoil/stiffness of the lungs, and requires patient to swallow an esophageal balloon.

E. Pulmonary stress testing is done in two forms:

1)  Simple pulmonary stress testing is a test that allows quantification of workload and heart rate activity, while measuring the degree of oxygen desaturation. This test is undertaken to measure the degree of hypoxemia or desaturation that occurs with exertion and to optimize titration of supplemental oxygen for the correction of hypoxemia.

2)  A more complex test involves the measurements of oxygen uptake, CO2 production, and O2 for following: to distinguish between cardiac and pulmonary causes for dyspnea; determine the need for and dose of ambulatory oxygen; assist in developing a safe exercise prescription for patients with cardiovascular or pulmonary disease; predict the morbidity of lung resection; or titrate optimal settings in selected patients who have physiologic pacemakers.

F. The use of spirometry, bronchodilation spirometry, respiratory volume flow loop, vital capacity, maximum breathing capacity or plethysmography for lung volumes, diffusing capacity to diagnose or manage patients with asthma or COPD is considered medically necessary and does not require prior authorization.

G. For any advanced pulmonary function testing a pulmonologist consultation should be considered. Unless ordered or performed by a pulmonologist, less commonly used Pulmonary Function tests including following require prior authorization:

   i)  Bronchospasm provocation testing

   ii)  Exercise test for bronchospasm

   iii)  Pulmonary stress testing, with measurement of heart rate, oximetry, & oxygen    

         titration

    iv)   Cardiopulmonary exercise testing

    v)  Oxygen uptake, expired gas analysis; rest & exercise

     vi)  Carbon dioxide, expired gas determination by infrared analyzer

H. Pulmonary Function Testing is not considered medically necessary and not covered when:

1)   A diagnosis or evaluation can be made clinically; or

2)   When test results are not necessary to manage the patient’s disease; or

3)    On routine visits for other medical conditions, when there is no signs and symptoms of clinically meaningful changes in pulmonary status; or

4)    Routine use of PFTs at each office visit; or

5)    Spirometry is the main test, additional testing without above indications.

Codes Used In This BI:

Pulmonary function testing is not covered for routine preoperative evaluations.

1)    Qaseem A, et al. Risk Assessment for and Strategies to Reduce Perioperative Pulmonary Complications for Patients Undergoing Noncardiothoracic Surgery: A Clinical Guideline from the American College of Physicians. Ann Intern Med. 2006; 144(8):575-580.

2)    Colice GL, et al. Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition). Chest. 2007; 132(3_suppl):161S-177S.

3)    Pulmonary Function testing – Medicare Local Coverage Determination (LCD) – Noridian  https://med.noridianmedicare.com/documents/10525/5321621/Local+Coverage+Determination+for+Pulmonary+Function+Testing+%28L34247%29

Addendum:

1)    Effective 11/01/2017: Added that pulmonary function tests require prior authorization unless performed by a pulmonologist.

2)    Effective 1/1/2018: 2018 Code Updates. Deleted CPT code 94620 from Claim Statement section. This code was replaced with new CPT codes 94617 – 94618.

3)    Effective 08/01/2018: Removed PA requirements for some PFT’s (94726-94729).

4)    Effective 01/01/2020: Code update: Code 94728 revised eff 01/01/2020.

5)    Effective 01/01/2021: Updated code 94617 and deleted codes 94250 and 94770, and separated code ranges in search box to make searchable.