TL;DR: The Centers for Medicare & Medicaid Services modified NCD 119 governing lung volume reduction surgery coverage, with an effective date of March 7, 2026. Here's what billing teams need to know before submitting claims.
CMS lung volume reduction surgery coverage policy under NCD 119 Medicare has been updated. This modification affects thoracic surgery programs, pulmonology practices, and hospital outpatient departments billing for LVRS — also documented in claims as reduction pneumoplasty, lung shaving, or lung contouring. The policy does not list specific CPT codes in this version, but the clinical and facility criteria that drive medical necessity determinations have been restated and reaffirmed. Your billing team needs to understand exactly what CMS requires before any claim leaves your system.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | Lung Volume Reduction Surgery (Reduction Pneumoplasty) |
| Policy Code | NCD 119 |
| Change Type | Modified |
| Effective Date | 2026-03-07 |
| Impact Level | High |
| Specialties Affected | Thoracic Surgery, Pulmonology, Inpatient Hospital, Outpatient Hospital |
| Key Action | Audit your LVRS patient selection and facility approval documentation against NCD 119 criteria before submitting claims dated on or after March 7, 2026 |
CMS Lung Volume Reduction Surgery Coverage Criteria and Medical Necessity Requirements 2026
This coverage policy is strict. CMS will only consider LVRS reasonable and necessary when a specific, layered set of patient, surgical, and facility requirements are all met simultaneously. Miss one, and you're looking at a claim denial.
The effective date for the nationally covered indications is January 1, 2004 — but this modified policy, effective March 7, 2026, reaffirms and restates those standards. That matters because it signals CMS is actively maintaining this NCD, not letting it sit dormant.
Patient Selection Criteria
Every LVRS patient must meet all of the following before you can support a medical necessity determination:
| # | Covered Indication |
|---|---|
| 1 | History and physical: Findings must be consistent with emphysema |
| 2 | BMI: ≤31.1 kg/m² for men, ≤32.3 kg/m² for women |
| 3 | Corticosteroid use: Stable on ≤20 mg prednisone (or equivalent) per day |
| 4 | Radiographic findings: Consistent with emphysema (CT scan required) |
| 5 | Pulmonary function: Specific spirometry thresholds must be met — FEV₁ and other measures are documented in the full NCD |
| 6 | Arterial blood gas: PCO₂ and PO₂ criteria must be satisfied |
| 7 | Cardiac status: Must meet cardiac clearance thresholds |
| 8 | Rehabilitation: Patient must have completed a Medicare-approved pulmonary rehabilitation program prior to surgery |
| 9 | Oxygen use: Documented history must align with policy thresholds |
| 10 | Smoking cessation: Patient must have stopped smoking, with documentation of cessation for a defined pre-operative period |
This is a checklist, not a suggestion list. Every item needs documentation in the medical record before billing.
Approved Surgical Approaches
CMS covers only two surgical techniques for LVRS:
| # | Covered Indication |
|---|---|
| 1 | Bilateral excision with stapling via median sternotomy |
| 2 | Bilateral excision with stapling via video-assisted thoracoscopic surgery (VATS) |
Unilateral approaches are not covered under this policy. Neither are bronchoscopic lung volume reduction procedures — those are addressed under separate national coverage policy framework. If your surgeons are performing anything other than bilateral stapled excision via one of these two approaches, stop and assess whether NCD 119 applies at all.
Facility Requirements
This is where LVRS billing gets complicated. Not every hospital can bill for covered LVRS under NCD 119. CMS has tiered the facility approval requirements with different effective dates built into the policy.
Facilities must meet specific criteria — including data submission requirements to a national registry, volume thresholds, and quality standards — to qualify as an approved LVRS site. The full requirements with their specific effective dates are in the NCD 119 policy document. If your facility's approval status has lapsed or was never established, your LVRS claims will not be reimbursed regardless of how well the patient meets selection criteria.
Pull your facility's approval documentation now. Do not assume it's current.
Prior Authorization
NCD 119 does not explicitly mandate prior authorization as a step separate from the coverage criteria. However, Medicare Administrative Contractors in your region may have local coverage determination policies that add prior auth requirements on top of the NCD. Check with your MAC before scheduling LVRS and billing. This is not a step to skip.
CMS LVRS Exclusions and Non-Covered Indications
CMS is explicit about what does not qualify as covered LVRS. Your lung volume reduction surgery billing team needs to flag these situations before claims are submitted.
Unilateral LVRS is not covered. CMS requires bilateral excision. A claim for unilateral lung volume reduction will not meet the coverage policy criteria and will deny.
Non-emphysema diagnoses do not qualify. The policy is specific to severe emphysema. Patients with other obstructive or restrictive lung diseases — even if they have lung hyperinflation — do not meet the indication under NCD 119.
High-risk patients who fall outside the patient selection criteria are excluded. CMS identified a specific "high-risk" subgroup in the NETT trial data: patients with FEV₁ ≤20% predicted and either homogeneous emphysema distribution or DLCO ≤20% predicted. CMS does not cover LVRS for this subgroup. This is a hard exclusion — not a gray zone. Document why your patient does not fall into this category.
Facilities not meeting NCD 119 approval criteria cannot bill for covered LVRS services, regardless of patient eligibility. The facility qualification and the patient qualification are both required.
Bronchoscopic approaches — including endobronchial valve procedures and other minimally invasive lung volume reduction techniques — are not covered under NCD 119. Those are distinct procedures and fall under separate coverage policy determinations.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Bilateral LVRS via median sternotomy in patients meeting all NCD 119 criteria | Covered | Not listed in policy | All patient, surgical, and facility criteria must be met |
| Bilateral LVRS via VATS in patients meeting all NCD 119 criteria | Covered | Not listed in policy | All patient, surgical, and facility criteria must be met |
| LVRS in "high-risk" patients (FEV₁ ≤20% and homogeneous emphysema or DLCO ≤20%) | Not Covered | Not listed in policy | Excluded per NETT trial findings |
| Unilateral LVRS | Not Covered | Not listed in policy | Bilateral approach required |
| Bronchoscopic lung volume reduction (endobronchial valves, etc.) | Not Covered under NCD 119 | Not listed in policy | Addressed under separate NCD framework |
| LVRS at non-approved facilities | Not Covered | Not listed in policy | Facility must meet NCD 119 approval requirements |
| LVRS for non-emphysema diagnoses | Not Covered | Not listed in policy | Policy is emphysema-specific |
CMS Lung Volume Reduction Surgery Billing Guidelines and Action Items 2026
The modified NCD 119 effective March 7, 2026 gives your team a clear deadline. Here's what to do before and after that date.
| # | Action Item |
|---|---|
| 1 | Audit your facility's NCD 119 approval status immediately. Contact your thoracic surgery program director and pull documentation confirming your facility meets all CMS approval criteria under NCD 119. If that documentation doesn't exist or is outdated, escalate to your compliance officer before scheduling any LVRS claims for submission dated on or after March 7, 2026. |
| 2 | Build a pre-billing checklist from the patient selection criteria. Every LVRS case needs a documented check against all NCD 119 patient criteria — BMI, corticosteroid dose, pulmonary function tests, arterial blood gas results, cardiac clearance, rehabilitation completion, and smoking cessation. Your clinical documentation team and surgeons need to know this list cold. A missing checkbox means a denied claim. |
| 3 | Confirm the surgical approach is bilateral and stapled. Before billing, verify the operative report explicitly documents bilateral excision with stapling via median sternotomy or VATS. A unilateral approach or any bronchoscopic technique will not support reimbursement under NCD 119. Don't rely on the surgeon's verbal summary — read the op report. |
| 4 | Check your MAC for any local coverage determination layered on top of NCD 119. NCDs set the floor. Your Medicare Administrative Contractor may have additional LCD requirements, prior authorization steps, or documentation standards in your region. Run this check now — don't wait until a claim bounces back. |
| 5 | Train your coding team on the "high-risk exclusion." The NETT-derived high-risk subgroup (FEV₁ ≤20% predicted plus homogeneous emphysema or DLCO ≤20% predicted) is a hard non-covered category. If coders or pre-auth staff aren't screening for this, you will submit and lose claims. Put this in your internal billing guidelines as a hard stop. |
| 6 | Document pulmonary rehabilitation completion in the claim record. Pre-operative participation in a Medicare-approved pulmonary rehabilitation program is a coverage condition, not a recommendation. The medical record must show completion before surgery. If it's not in the chart, it didn't happen as far as CMS is concerned. |
| 7 | Loop in your compliance officer if your LVRS volume is significant. This policy carries high financial exposure per case — LVRS is a major inpatient procedure. If you bill more than a handful of these per year, a formal internal audit against NCD 119 criteria before the March 7, 2026 effective date is worth the time investment. |
| 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
Codes Listed in the Policy
NCD 119 (version 119-v3, modified effective March 7, 2026) does not list specific CPT, HCPCS Level II, or ICD-10-CM codes in the published policy data.
This is a known gap with some older NCDs that were written before the current coding structure. It does not mean your claims don't need codes — it means you need to work with your coding team and MAC to confirm the appropriate procedure codes for LVRS under median sternotomy and VATS approaches.
If you're unsure which CPT codes your MAC expects for LVRS claims under NCD 119, call your MAC's provider services line directly. Get the answer in writing.
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