Medicare AdvantageCoverageMedium impact
Endobronchial Valve Therapy for Emphysema - Medicare Advantage (Revised)
Humana·Pulmonology, Critical Care, Internal Medicine·Medicare Advantage
Effective date
Jul 1, 2026
We identified it
Jun 30, 2026
Summary
Humana Medicare Advantage has revised its coverage policy for Endobronchial Valve (EBV) therapy for severe emphysema, effective July 1, 2026. The policy establishes specific clinical criteria for initial valve placement (CPT 31647, 31651) and detailed indications for valve removal/replacement (CPT 31648, 31649). Billing teams must ensure prior authorization requests include all required clinical documentation and pulmonary function test results to avoid claim denials.
Action Required
By June 1, 2026: Billing team must update prior authorization protocols and clinical documentation requirements for EBV procedures. Specifically: (1) Create pre-authorization checklist requiring providers to submit all mandatory clinical criteria including HRCT scan results, pulmonary rehabilitation completion within 6 months, smoking abstinence verification (4+ months), and specific pulmonary function values (FEV1 15-45%, RV ≥150%, TLC ≥100%, DLCO >20%, BMI 15-35); (2) Update billing system to require documentation of absence of contraindications (no active infection, no alpha-1 antitrypsin deficiency, no recent COPD exacerbation within 90 days, no uncontrolled pulmonary hypertension); (3) Establish separate authorization pathways for initial placement (CPT 31647, 31651) versus removal/replacement procedures (CPT 31648, 31649), as removal/replacement requires only ONE of the stated clinical indicators rather than ALL criteria; (4) Flag claims for manual review if any required clinical data is missing. Providers must submit complete pulmonary function test results and imaging with authorization requests. Claims submitted without required clinical documentation will be denied. Communicate updated requirements to all pulmonology and interventional bronchoscopy providers before July 1, 2026.