TL;DR: The Centers for Medicare & Medicaid Services modified NCD 119 governing lung volume reduction surgery (LVRS), effective March 7, 2026. Here's what billing teams need to know before submitting claims.
This update to the CMS lung volume reduction surgery coverage policy keeps the core structure in place — but the criteria are detailed, layered, and unforgiving. Miss one element, and you're looking at a claim denial. This policy does not list specific CPT or HCPCS codes, so your team needs to cross-reference current procedure codes against these medical necessity requirements directly.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Centers for Medicare & Medicaid Services (CMS) |
| Policy | Lung Volume Reduction Surgery (Reduction Pneumoplasty) |
| Policy Code | NCD 119 Medicare |
| Change Type | Modified |
| Effective Date | March 7, 2026 |
| Impact Level | High |
| Specialties Affected | Thoracic Surgery, Pulmonology, Inpatient Hospital Billing, Outpatient Hospital Billing |
| Key Action | Audit your LVRS pre-authorization and documentation workflows against all three coverage criteria tiers before submitting claims |
CMS Lung Volume Reduction Surgery Coverage Criteria and Medical Necessity Requirements 2026
NCD 119 is the National Coverage Determination governing Medicare coverage of lung volume reduction surgery — also called reduction pneumoplasty, lung shaving, or lung contouring. The Centers for Medicare & Medicaid Services covers LVRS for patients with severe emphysema. The goal is to remove damaged lung tissue so the remaining lung can expand and improve respiratory function.
Medicare-covered LVRS is limited to two surgical approaches: bilateral excision of damaged lung with stapling via median sternotomy, or video-assisted thoracoscopic surgery (VATS). Any other technique falls outside this coverage policy. That's a hard line — document the surgical approach explicitly in your operative notes.
For the coverage policy to apply, services must have been performed on or after January 1, 2004. The effective date of March 7, 2026 governs this modified version of the NCD. Medical necessity under NCD 119 requires meeting all three tiers of criteria simultaneously: patient-level criteria, surgical contraindication exclusions, and facility requirements.
Patient-Level Medical Necessity Criteria
The patient must meet every one of the following before LVRS qualifies as covered:
| # | Covered Indication |
|---|---|
| 1 | History and physical exam consistent with emphysema |
| 2 | BMI ≤31.1 kg/m² for men or ≤32.3 kg/m² for women |
| 3 | Medically stable on ≤20 mg prednisone (or equivalent) per day |
| 4 | Radiographic findings consistent with emphysema (typically bilateral, with evidence of hyperinflation) |
| 5 | Post-bronchodilator FEV₁ ≤45% predicted (≤15% predicted for patients 70 and older) |
| 6 | Total lung capacity (TLC) ≥100% predicted post-bronchodilator |
| 7 | Residual volume (RV) ≥150% predicted post-bronchodilator |
| 8 | Arterial PCO₂ ≤60 mmHg (≤55 mmHg at altitude above 3,000 feet) |
| 9 | Arterial PO₂ ≥45 mmHg (≥30 mmHg at altitude above 3,000 feet) |
| 10 | Six-minute walk distance ≥140 meters |
| 11 | Completed pulmonary rehabilitation — at least 16 sessions over 6-10 weeks — or documented contraindication |
| 12 | Non-smoking for at least four months prior to the evaluation, verified by arterial carboxyhemoglobin or cotinine levels |
Every item on that list needs documentation in the medical record. If your team handles LVRS billing, build a pre-submission checklist that maps directly to these criteria. One missing data point triggers a medical necessity denial.
Prior Authorization and Facility Requirements
Prior authorization requirements under NCD 119 tie directly to facility eligibility. CMS does not cover LVRS at just any hospital. The facility must meet specific criteria, and those criteria have varying effective dates within the policy.
Your facility must be an approved LVRS site. This requires CMS certification based on institutional experience, surgical volume, and outcomes data. Confirm your facility's certification status before submitting claims — especially if your organization recently changed ownership, merged, or shifted service lines. Billing for LVRS at a non-approved facility results in a claim denial regardless of how well the patient meets clinical criteria.
The benefit categories covered under this NCD include inpatient hospital services, outpatient hospital services incident to a physician's service, and physicians' services. LVRS billing can occur across all three settings, so your revenue cycle team needs to coordinate documentation requirements across each.
CMS Lung Volume Reduction Surgery Exclusions and Non-Covered Indications
This is where NCD 119 gets strict. CMS explicitly excludes patients from LVRS coverage if any of the following surgical contraindications are present:
| # | Excluded Procedure |
|---|---|
| 1 | Prior lobectomy, prior LVRS, or prior lung transplant — on either side |
| 2 | Giant bulla (single bulla occupying >1/3 of the hemithorax) |
| 3 | Pulmonary hypertension — defined as mean pulmonary artery pressure >35 mmHg or peak >45 mmHg by right heart catheterization |
| 4 | Presence of systemic disease or other conditions that substantially increase surgical risk |
| 5 | Requirement for ventilator-dependent respiration |
| 6 | Active pleural space disease |
CMS also designates certain patient profiles as non-covered specifically because the National Emphysema Treatment Trial (NETT) identified them as high-risk with no demonstrated benefit. These are not gray areas — they are explicitly non-covered:
| # | Excluded Procedure |
|---|---|
| 1 | FEV₁ ≤20% predicted AND either homogeneous emphysema distribution on CT OR DLCO ≤20% predicted |
If a patient presents with these findings, LVRS is non-covered under Medicare. Document that you assessed and ruled out these exclusion criteria. Lack of documentation on exclusions is just as risky as lack of documentation on inclusion criteria.
Unilateral LVRS is also not a covered approach under this policy. Medicare requires bilateral excision. Billing for a unilateral procedure will not meet the coverage definition.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Bilateral LVRS via median sternotomy for severe emphysema (all patient criteria met) | Covered | No specific codes listed in NCD 119 | All patient, contraindication, and facility criteria must be met |
| Bilateral LVRS via video-assisted thoracoscopic surgery (VATS) for severe emphysema | Covered | No specific codes listed in NCD 119 | Same full criteria apply; document approach explicitly |
| LVRS in patients with FEV₁ ≤20% predicted + homogeneous emphysema on CT | Not Covered | No specific codes listed in NCD 119 | NETT high-risk designation; Medicare exclusion |
| LVRS in patients with FEV₁ ≤20% predicted + DLCO ≤20% predicted | Not Covered | No specific codes listed in NCD 119 | NETT high-risk designation; Medicare exclusion |
| Unilateral LVRS (any approach) | Not Covered | No specific codes listed in NCD 119 | Coverage limited to bilateral excision only |
| LVRS following prior lobectomy, prior LVRS, or lung transplant | Not Covered | No specific codes listed in NCD 119 | Surgical contraindication per NCD 119 |
| LVRS with pulmonary hypertension (mean PA pressure >35 mmHg or peak >45 mmHg) | Not Covered | No specific codes listed in NCD 119 | Right heart catheterization data required to document |
| LVRS with giant bulla (>1/3 of hemithorax) | Not Covered | No specific codes listed in NCD 119 | Radiographic documentation required |
| LVRS at a non-approved, non-certified facility | Not Covered | No specific codes listed in NCD 119 | Facility certification is a hard coverage requirement |
CMS Lung Volume Reduction Surgery Billing Guidelines and Action Items 2026
The real issue with LVRS billing is documentation density. This is one of the most criteria-heavy NCDs in Medicare. Gaps in documentation don't just risk a denial — they risk a post-payment audit finding that requires repayment. Here's what your team needs to do now.
| # | Action Item |
|---|---|
| 1 | Build a pre-submission documentation checklist tied to each patient criterion. Every item in Section B.1 of NCD 119 needs a corresponding data point in the medical record. BMI, pulmonary function results, steroid dosage, carboxyhemoglobin or cotinine levels, six-minute walk results, pulmonary rehab completion — all of it. If any single criterion is missing from the record, hold the claim until it's resolved. |
| 2 | Confirm your facility's CMS certification for LVRS before submitting any claims. Contact your Medicare Administrative Contractor (MAC) if you're unsure of your facility's current approval status. A claim submitted for LVRS at an unapproved facility will deny, and the fix isn't a simple corrected claim — it's a coverage eligibility problem that requires resolution before resubmission. |
| 3 | Document the surgical approach explicitly in every operative report. Median sternotomy or VATS — the approach must be stated clearly. Unilateral procedures are not covered. If the operative note doesn't specify bilateral excision with stapling, your claim is exposed. |
| 4 | Screen every LVRS candidate against the NETT high-risk exclusions before billing. If a patient has FEV₁ ≤20% predicted, your pre-op workup must include both CT distribution assessment and DLCO. Document that you evaluated these criteria and that the patient did not meet the exclusion thresholds. This protects the claim on audit. |
| 5 | Verify pulmonary rehab completion and document it as a covered session count. CMS requires at least 16 sessions over 6-10 weeks. Document the number of sessions, the date range, and the supervising provider. If rehab was contraindicated, document that contraindication explicitly — "patient could not complete pulmonary rehab" is not sufficient. The contraindication needs a clinical basis in the record. |
| 6 | Coordinate with your compliance officer on the modified NCD 119 criteria before the next LVRS case. The policy modification effective March 7, 2026 warrants a fresh review of your current documentation templates and pre-authorization workflows. If your team hasn't updated LVRS charge capture processes to reflect the current NCD requirements, do it now — not after the first denial. |
| 7 | Identify the correct LVRS procedure codes with your MAC. NCD 119 does not list specific CPT or HCPCS codes in this version of the policy. Contact your MAC or check the applicable local coverage determination (LCD) for your region to confirm which procedure codes your MAC expects for LVRS claims. Regional variation exists. Don't assume your current code assignment is correct without verifying. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Lung Volume Reduction Surgery Under NCD 119
NCD 119 does not list specific CPT, HCPCS Level II, or ICD-10-CM codes in the current policy data. This is not unusual for older NCDs — but it creates a real LVRS billing problem for your team.
Without a code list embedded in the NCD, your coverage policy compliance depends on correctly pairing the right procedure codes with the NCD's coverage criteria. The wrong code on a covered procedure is still a denial.
Take these steps:
- Check your MAC's website for any companion LCD or coding article tied to NCD 119. Several MACs publish coding guidance that maps LVRS procedure codes to this NCD.
- Contact your MAC directly to confirm the expected CPT codes for median sternotomy-based LVRS and VATS-based LVRS before billing.
- Review your ICD-10-CM coding for emphysema diagnoses — the diagnosis code on the claim must support the medical necessity criteria in the NCD, particularly the severity of emphysema.
If you're billing LVRS and haven't confirmed code alignment with your MAC, talk to your compliance officer before the next claim goes out. The reimbursement exposure on a wrongly coded thoracic surgery case is significant.
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