Was the bronchoscopy procedure, including transbronchial lung biopsy, bronchoscopy with fluoroscopy, and endobronchial ultrasound (codes 31628, 31623, 31652), medically necessary for the patient with a solid mass in the right upper lobe and mediastinal hilar adenopathy?

Medical Necessity Determination for Bronchoscopy Procedures

The bronchoscopy procedures (CPT 31628,31623,31652) performed on this patient were medically necessary and appropriate. The patient presented with a 4.9 cm solid mass in the right upper lobe with mediastinal and hilar adenopathy requiring tissue diagnosis to guide potentially curative treatment, which directly meets established clinical criteria for diagnostic bronchoscopy with EBUS-guided sampling.

Clinical Justification

Primary Indication: Lung Mass Requiring Tissue Diagnosis

The presence of a 4.9 x 4 x 3.3 cm solid mass in the right upper lobe with satellite nodules and mediastinal adenopathy constitutes a clear indication for bronchoscopic evaluation. 1 The British Thoracic Society guidelines specifically identify new or enlarging solitary nodules or masses on chest imaging as appropriate indications for lung biopsy when tissue diagnosis is needed. 1

• The patient's imaging demonstrated a substantial lung mass (4.9 cm) extending from the right hilum with associated mediastinal hilar adenopathy, including a 1.5 cm right paratracheal lymph node and 1.3 cm right hilar lymph node. 1

• Patients with lesions on chest radiograph should be discussed in a multidisciplinary meeting with a respiratory physician and radiologist at minimum, which appears to have occurred given the procedural planning documented. 1

Appropriateness of Bronchoscopy Over Alternative Approaches

Bronchoscopy was the optimal first-line diagnostic approach for this centrally-located hilar mass rather than percutaneous transthoracic needle biopsy. 1 The guidelines indicate that percutaneous biopsy should be considered when lesions are "not amenable to diagnosis by bronchoscopy or CT shows it is unlikely to be accessible by bronchoscopy." 1

• The mass extended from the right hilum, making it accessible via bronchoscopic approaches and reducing the pneumothorax risk compared to percutaneous approaches. 1

• The presence of mediastinal adenopathy requiring staging made EBUS-TBNA particularly appropriate as it could address both diagnosis and staging in a single procedure. 1, 2

Specific Procedure Code Justification

CPT 31628 (Transbronchial Lung Biopsy) and 31623 (Bronchoscopy with Biopsy)

Transbronchial biopsies and brushings of the right upper lobe mass were medically necessary to obtain tissue for histopathological diagnosis. 1 The procedure note documents that "multiple brushes and transbronchial biopsies were done under fluoroscopy" from the right upper lobe, which is the standard approach for peripheral lung masses. 1

• The use of fluoroscopic guidance during transbronchial biopsy is appropriate for peripheral lesions to ensure accurate sampling and minimize complications. 1

• The preliminary pathology showing "suspicious for cancer" validates that diagnostic tissue was successfully obtained, confirming the technical appropriateness of the procedure. 1

CPT 31652 (EBUS with Sampling of Lymph Nodes)

EBUS-guided fine needle aspiration of mediastinal lymph nodes was medically necessary for both diagnosis and staging. 1, 2 The ACR Appropriateness Criteria rate endoscopic/bronchoscopic biopsy as "8" (usually appropriate) for patients with pulmonary nodules and mediastinal adenopathy. 1

• The procedure documented "multiple FNA passes were done from station 4R" (right paratracheal), which is appropriate given the 1.5 cm lymph node identified on pre-procedure CT. 1, 2

• EBUS-TBNA has become the procedure of choice to sample hilar and mediastinal adenopathy, with the ability to provide both diagnosis and staging information critical for treatment planning. 2

• The European Respiratory Society/American Thoracic Society statement indicates that TBNA for staging of bronchogenic carcinoma by sampling mediastinal and hilar lymph nodes is a major application of the technique. 1

Impact on Morbidity, Mortality, and Quality of Life

Obtaining a definitive tissue diagnosis through bronchoscopy was essential to guide potentially curative treatment and avoid unnecessary surgical morbidity. 1 The subsequent case history shows the patient received targeted chemotherapy (carboplatin, pembrolizumab, pemetrexed) for confirmed lung cancer, which would not have been possible without tissue diagnosis.

• Accurate diagnosis of benign lesions using cutting needle biopsy has reduced the need for diagnostic surgery by up to 50%, avoiding the 2-3% mortality risk of lobectomy and significant post-thoracotomy pain in approximately 10% of patients. 1

• Thoracic surgery carries significant mortality and morbidity due to cardiovascular causes and loss of lung function, making non-surgical tissue diagnosis preferable when feasible. 1

• Delays in lung cancer care may lead to missed opportunities for cure or palliation and emotional distress, making timely bronchoscopic diagnosis critical. 1

• The ability to distinguish between small cell and non-small cell lung cancer, and to obtain molecular markers for targeted therapy, directly impacts treatment selection and survival outcomes. 1

Procedural Safety and Appropriateness

The procedure was performed with appropriate safety measures and technique:

• Fluoroscopic guidance was used for transbronchial biopsies to ensure accurate sampling and minimize complications. 1

• Minimal bleeding occurred and was appropriately managed with topical epinephrine. 1

• The normal tracheobronchial tree examination ruled out endobronchial lesions that might have been more easily accessible. 1

The diagnostic yield was successful, with preliminary pathology showing suspicious findings that led to definitive cancer diagnosis and appropriate systemic therapy. 1, 2