Medical Policy
Effective Date:09/01/2013 Title:Exhaled Breath Tests for Lung Inflammation
Revision Date: Document:BI414:00
CPT Code(s):83987, 95012
Public Statement

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.

The measurement of exhaled nitric oxide is used to indicate inflammation in the lungs in conditions such as asthma. It is considered investigational as there is insufficient evidence of its effectiveness.

The measurement of exhaled condensate pH is also used in assessing lung inflammation and it is considered investigational due to lack of evidence that it is effective.
Medical Statement
  1. QualChoice considers measurement of exhaled nitric oxide experimental and investigational for assessment of asthma, lung cancer, other pulmonary diseases, (e.g., chronic obstructive pulmonary disease, pulmonary tuberculosis, sino-nasal disease) and all other conditions because of insufficient evidence of its effectiveness.
  2. QualChoice considers measurement of exhaled breath condensate (EBC) pH experimental and investigational for assessment of asthma, lung cancer, other pulmonary diseases, and all other conditions because of insufficient evidence of its effectiveness.

Codes Used In This BI:

 

83987

95012
Limits
Intentially left empty
Reference
Powell H, Murphy VE, Taylor DR, et al. Management of asthma in pregnancy guided by measurement of fraction of exhaled nitric oxide: A double-blind, randomised controlled trial. Lancet. 2011;378(9795):983-990. Yoon HI, Sin DD. Biomarkers of therapeutic response in patients with chronic obstructive pulmonary disease: A critical review of the literature. Drugs. 2011;71(14):1821-1837. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention 2011 (update). Bethesda, MD: Global Initiative for Asthma (GINA); December 2011. Lester D, Mohammad A, Leach EE, et al. An investigation of asthma care best practices in a community health center. J Health Care Poor Underserved. 2012;23(3 Suppl):255-264. Rosenberg SR, Kalhan R. Biomarkers in chronic obstructive pulmonary disease. Transl Res. 2012;159(4):228-237. Jartti T, Wendelin-Saarenhovi M, Heinonen I, et al. Childhood asthma management guided by repeated FeNO measurements: A meta-analysis. Paediatr Respir Rev. 2012;13(3):178-183. Pike K, Selby A, Price S, et al. Exhaled nitric oxide monitoring does not reduce exacerbation frequency or inhaled corticosteroid dose in paediatric asthma: A randomised controlled trial. Clin Respir J. 2012 Jul 2. [Epub ahead of print] Petsky HL, Cates CJ, Lasserson TJ, et al. A systematic review and meta-analysis: Tailoring asthma treatment on eosinophilic markers (exhaled nitric oxide or sputum eosinophils). Thorax. 2012;67(3):199-208. Calhoun WJ, Ameredes BT, King TS, et al.; Asthma Clinical Research Network of the National Heart, Lung, and Blood Institute. Comparison of physician-, biomarker-, and symptom-based strategies for adjustment of inhaled corticosteroid therapy in adults with asthma: The BASALT randomized controlled trial. JAMA. 2012;308(10):987-997. O’Connor GT, Reibman J. Inhaled corticosteroid dose adjustment in mild persistent asthma. JAMA. 2012;308(10):1036-1037. Chladkova J, Krcmova I, Chladek J, et al. Validation of nitrite and nitrate measurements in exhaled breath condensate. Respiration. 2006;73(2):173-179. Zacharasiewicz A, Erin EM, Bush A. Noninvasive monitoring of airway inflammation and steroid reduction in children with asthma. Curr Opin Allergy Clin Immunol. 2006;6(3):155-160. Boyce PD, Kim JY, Weissman DN, et al. pH increase observed in exhaled breath condensate from welding fume exposure. J Occup Environ Med. 2006;48(4):353-356. Baraldi E, Carraro S. Exhaled NO and breath condensate. Paediatr Respir Rev. 2006;7 Suppl 1:S20-S22. Ko FW, Leung TF, Hui DS. Are exhaled breath condensates useful in monitoring asthma? Curr Allergy Asthma Rep. 2007;7(1):65-71. Cepelak I, Dodig S. Exhaled breath condensate: A new method for lung disease diagnosis. Clin Chem Lab Med. 2007;45(8):945-952. Borrill ZL, Roy K, Singh D. Exhaled breath condensate biomarkers in COPD. Eur Respir J. 2008;32(2):472-486. National Institutes of Health (NIH), National Heart, Lung, and Blood Institute, National Asthma Education Program. Expert panel report 3: Guidelines for the diagnosis and management of asthma. Full Report 2007. Bethesda, MD: NIH; 2007. Chan HP, Lewis C, Thomas PS. Exhaled breath analysis: Novel approach for early detection of lung cancer. Lung Cancer. 2009;63(2):164-168. Dalaveris E, Kerenidi T, Katsabeki-Katsafli A, et al. VEGF, TNF-alpha and 8-isoprostane levels in exhaled breath condensate and serum of patients with lung cancer. Lung Cancer. 2009;64(2):219-225. Fila L, Musil J. Examination of exhaled breath condensate in cystic fibrosis. Cas Lek Cesk. 2010;149(4):173-177. Popov TA. Human exhaled breath analysis. Ann Allergy Asthma Immunol. 2011;106(6):451-456; quiz 457. Teng Y, Sun P, Zhang J, et al. Hydrogen peroxide in exhaled breath condensate in patients with asthma: A promising biomarker? Chest. 2011;140(1):108-116.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.