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MP 7.01.45

Endoscopic Laser for Tracheobronchial Obstructions

Medical Policy
Original Policy Date
Last Review Status/Date
Reviewed by consensus/2:2003
Return to Medical Policy Index


Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


A laser can be used endoscopically to resect tracheobronchial obstructions. The laser fibers are directed to the obstruction by either a rigid bronchoscope or a flexible fiberscope. The laser then uses light and heat energy to coagulate tissue and remove the obstruction.


The use of an endoscopic laser is considered medically necessary in treating obstructions of the trachea or either right or left main bronchus.

The use of an endoscopic laser in treating obstructions of the segmental or lobar bronchi is considered investigational.

Policy Guidelines

No applicable information

Benefit Application

BlueCard/National Account Issues

No applicable information


A search of the literature was completed through the MEDLINE database for the period of January 1992 through February 1995. The search strategy focused on references containing the following Medical Subject Headings:

– Bronchi
– Laser Surgery
– Obstruct
– Stenosis
– Trachea

Research was limited to English-language journals on humans.

See also:

Technology Evaluation and Coverage 1986: p.189





CPT  31641  Bronchoscopy, with destruction of tumor or relief of stenosis by any method other than excision 
ICD-9 Procedure  32.01  Endoscopic excision or destruction of lesion or tissue of bronchus (Note: There is no “endoscope” specific code for “Trachea”) 
ICD-9 Diagnosis  012.8  Other specified respiratory tuberculosis 
  095.8  Other specified forms of late symptomatic syphilis 
    Note: 095.8, 012.8 are listed in the ICD-9 Index as causes of tracheobronchial obstructions. They may or may not apply 
  162.0  Malignant neoplasm of trachea (primary) 
  162.2  Malignant neoplasm main bronchus (primary) 
  197.0  Secondary malignant neoplasm lung (bronchus) 
  197.3  Secondary malignant neoplasm other respiratory organs (trachea) 
  212.2  Benign neoplasm of trachea 
  212.3  Benign neoplasm bronchus and lung 
  231.1  Carcinoma in situ of trachea 
  231.2  Carcinoma in situ bronchus and lung 
  235.7  Neoplasm of uncertain behavior trachea, bronchus, and lung 
  239.1  Neoplasm of unspecified nature respiratory system 
  519.1  Other diseases of trachea and bronchus NEC 
  748.3  Other anomalies of larynx, trachea, and bronchus 
HCPCS  No Code   
Type of Service  Surgery 
Place of Service  Inpatient


Endoscopic laser for tracheobronchial obstruction
Laser for tracheobronchial obstruction
Obstruction, tracheobronchial, laser

Policy History

Date Action Reason
3/31/96 Add to Surgery section New policy
8/18/00 Replace policy Archived policy
7/12/02 Replace policy Policy reviewed by consensus; new review date only
07/17/03 Replace policy Policy reviewed by consensus; no change in policy; no further review scheduled

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