Electromagnetic Navigational Bronchoscopy (ENB)

Policy ID: M-85-004

Section: Diagnostic Medical

Effective Date: January 04, 2021

Revised Date: December 08, 2024

Revision Effective Date: January 01, 2025

Last Reviewed: January 14, 2025

Applies To: Commercial and Medicaid Expansion

Description

Electromagnetic navigation bronchoscopy (ENB) is intended to enhance standard bronchoscopy by providing a three-dimensional roadmap of the lungs and real-time information about the position of the steerable probe during bronchoscopy. The purpose of ENB is to allow navigation to distal regions of the lungs, so that suspicious lesions can be biopsied and to allow fiducial markers placement.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; and/or

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

When flexible bronchoscopy alone, or with endobronchial ultrasound, is considered inadequate to accomplish the diagnostic or interventional objective, electromagnetic navigation bronchoscopy (ENB) may be considered medically necessary to:

Establish a diagnosis of suspicious peripheral pulmonary lesion(s) or
To place fiducial markers within lung tumor(s) prior to treatment.

Electronic navigational bronchoscopy not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

31626

31627

A4648

Outpatient HCPCS (C Code)

C1739

C9751

Diagnosis Codes

C34.00

C34.01

C34.02

C34.11

C34.12

C34.30

C34.31

C34.32

C34.80

C34.81

C34.82

C34.90

C34.91

C34.92

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-2020 New policy

Internal Medical Policy Committee 11-23-2021 Annual Review

Internal Medical Policy Committee 11-29-2022 Revision

Updated with clarifying language

Internal Medical Policy Committee 11-15-2023-Annual Review no changes in criteria

Internal Medical Policy Committee 11-19-2024 Annual Review -no changes in criteria

Added Policy Application
* Special Note: With the arrival of January 2025 New codes from CMS post November IMPC. Procedure code C1739 has been added to January’s IMPC with the effective date of January 01, 2025.

Internal Medical Policy Committee 1-14-2025 Coding update - Effective January 01, 2025

Added procedure code C1739

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: M-85-003

Section: Diagnostic Medical

Effective Date: January 04, 2021

Revised Date: November 16, 2024

Revision Effective Date: January 06, 2025

Last Reviewed: November 19, 2024

Archived Date: December 31, 2024

Applies To: Commercial and Medicaid Expansion

Description

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Establish a diagnosis of suspicious peripheral pulmonary lesion(s) or
To place fiducial markers within lung tumor(s) prior to treatment.

Electronic navigational bronchoscopy not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

31626

31627

A4648

Outpatient HCPCS (C Code)

C9751

Diagnosis Codes

C34.00

C34.01

C34.02

C34.11

C34.12

C34.30

C34.31

C34.32

C34.80

C34.81

C34.82

C34.90

C34.91

C34.92

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-2020 New policy

Internal Medical Policy Committee 11-23-2021 Annual Review

Internal Medical Policy Committee 11-29-2022 Revision

Updated with clarifying language

Internal Medical Policy Committee 11-15-2023-Annual Review no changes in criteria

Internal Medical Policy Committee 11-19-2024 Annual Review -no changes in criteria

Added Policy Application
* Special Note: With the arrival of January 2025 New codes from CMS post November IMPC. Procedure code C1739 has been added to January’s IMPC with the effective date of January 01, 2025.

Medical Policies Quick Search

Electromagnetic Navigational Bronchoscopy (ENB)

Description

Policy Application

Criteria

Procedure Codes

Outpatient HCPCS (C Code)

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Procedure Codes

Outpatient HCPCS (C Code)

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer