Medicare AdvantageCoverageMedium impact
Endobronchial Valves for the Treatment of Emphysema - Medicare Advantage (Revised)
Humana·Pulmonology, Cardiothoracic Surgery·Medicare Advantage
Effective date
Jul 1, 2025
We identified it
Jun 24, 2026
Summary
Humana Medicare Advantage has established new medical necessity criteria for endobronchial valve placement for severe emphysema treatment, effective July 1, 2025. The policy defines specific requirements including pulmonary function test results, BMI limits, and contraindications that must be met for coverage approval.
Action Required
Before July 1, 2025: Billing team must update prior authorization workflows for CPT codes 31647, 31648, 31649, and 31651 to include Humana's specific medical necessity criteria including FEV1 15-45% predicted, BMI 15-35 kg/m2, 6-minute walk test of at least 100m, and completion of supervised pulmonary rehabilitation within 6 months. Update encounter forms to remind providers of contraindications including active smoking within 4 months and recent COPD exacerbations. Claims not meeting these criteria will be denied.