This document addresses nasal surgery for the treatment of obstructive sleep apnea (OSA) and snoring. 

Note: Please see the following related documents for additional information:

• SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea;
• SURG.00079 Nasal Valve Suspension.

Not Medically Necessary:

Nasal surgery employing any technique is considered not medically necessary for the treatment of snoring.

Investigational and Not Medically Necessary:

Nasal surgery employing any technique, including nasal valve surgery, septoplasty, turbinectomy, polypectomy and laser or radiofrequency ablation (volumetric tissue reduction) of the nasal turbinates is considered investigational and not medically necessary for the treatment of obstructive sleep apnea and other sleep related breathing disorders.

Studies suggest stimulation of receptors in the nasal airway improves muscle tone in the oropharynx, and increased nasal resistance results in increased negative intraluminal pressure, causing an increased tendency for the soft tissues of the upper airway (soft palate and pharyngeal walls) to collapse. In addition, nasal obstruction may lead to mouth breathing, and mouth opening, which, in turn, results in inferior movement of the mandible with associated decrease in pharyngeal diameter. The base of the tongue may also fall backwards reducing the posterior pharyngeal space. The rationale for nasal surgery is to improve nasal patency re-establishing physiological breathing and minimizing oral breathing during sleep; also to reduce nasal resistance and improve the negative intraluminal pressure which generates upper airway collapse.

However, studies have not demonstrated that reducing nasal obstruction and resistance from various causes and using various techniques, (e.g., septoplasty, turbinectomy, polypectomy, RFVTR of inferior nasal turbinates) correlates with a significant reduction in objective OSA indicators, such as the Apnea-Hypopnea Index (AHI) or nocturnal oxygen desaturation. Although some case reports have suggested that surgical correction of nasal obstruction may improve subjective daytime complaints in individuals with OSA, studies in general have been flawed by relatively small numbers of study subjects, the fact that nasal surgery is often performed in association with other surgical procedures, and lack of objective data regarding nasal resistance and OSA diagnostic variables.

In their June 2003 review article, Chen and Kushida concluded that, "The exact role obstructed nasal breathing plays in the pathogenesis of OSA type sleep disorders remains presumptive, and robust clinical studies to evaluate the contribution of nasal function remain elusive. More stringently controlled studies are needed."  Another review by Rappai concluded that, "To date, there are no compelling data to demonstrate causality between nasal obstruction and persistent sleep disordered breathing."  They point out that most of the studies reviewed in their 2003 review article are short term, or only examined subjective outcomes to evaluate the effect on sleep disordered breathing. The authors concluded that further studies are needed to prove specific causality.  There continues to be a lack of large, well designed clinical trials sufficiently powered to support the safety and efficacy of nasal surgical procedures for OSA.

Another proposed use of nasal surgical procedures is to improve compliance with continuous positive airway pressure (CPAP) use in individuals with OSA and nasal obstruction requiring high CPAP settings.  To date, CPAP intolerance has been investigated in small retrospective studies with some favorable evidence showing reduced postoperative CPAP titration levels by at least 1 cm water.  However, variable additional factors also impact CPAP compliance, such as individual perception of symptoms and improvement in sleepiness and daily function from initial use of CPAP.  For these reasons, larger, well designed studies are needed to confirm the durability of any beneficial effect on CPAP compliance from nasal surgical procedures for individuals with OSA (Friedman, 2009; Masdon, 2004; Weaver, 2008; Zonato, 2006).  An updated search (in 2012) of the published evidence has not provided additional scientific support for nasal surgical procedures for the treatment of OSA or snoring.

In addition to the above peer reviewed literature, the Institute for Clinical Systems Improvement (ICSI) published a guideline that addresses the topic of nasal surgery for sleep apnea (ICSI, 2008), the authors of which conclude, "There are no studies demonstrating the efficacy of tongue base radiofrequency ablation (RFA) or RFA turbinoplasty for treatment of OSA/Hypopnea syndrome (OSA/HS)…There are no controlled studies that evaluate the long-term effect of septoplasty on OSA." The guideline mentions that RFA of the soft palate has been used primarily for the treatment of snoring, and that perforation and tissue erosion are complications of this technique (ICSI, 2008).

It has been postulated that increased nasal resistance may contribute to, or be causative in, sleep related breathing disorders, such as OSA. Nasal procedures that have been performed for the treatment of OSA include the following:

• Nasal valve surgery; this involves the slit-like opening formed by the septum, the caudal end of the upper lateral nasal cartilage, the soft tissue overlying the piriform aperture, the floor of the nose, and the head of the inferior turbinate. Loss of stability of the lateral nasal wall with subsequent collapse can occur at the level of the nasal valve and may result from nasal muscle dysfunction, (e.g., from facial nerve palsy) or loss of skeletal support resulting from prior surgery. This collapse may be surgically corrected;
• Septal surgery or septoplasty to straighten and thin a deviated or otherwise abnormal nasal septum (using several different techniques);
• Surgery to correct nasal turbinate hypertrophy (enlargement/swelling) or deformity (turbinectomy); this may involve the use of laser or radiofrequency ablation as an alternative to turbinectomy;
• Nasal polypectomy (removal of nasal polyps). 

Chronic:  Refers to persistent conditions with symptoms that last over a long period of time.

Nasal turbinates:  The scroll-like bony plates with curved margins on the lateral wall of the nasal cavity.

Sleep apnea: Temporary stoppage of breathing during sleep, which can result in excessive daytime sleepiness.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When Services are Not Medically Necessary: 

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above for the diagnoses listed below; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Peer Reviewed Publications:

1. Bäck LJ, et al. Submucosal bipolar radiofrequency thermal ablation of inferior turbinates: a long term follow up with subjective and objective assessment. Laryngoscope. 2002; 112(10):1806-1812.
2. Bäck LJ, Hytonen ML, Roine RP, Malmivaara AV. Radiofrequency ablation treatment of soft palate for patients with snoring: a systematic review of effectiveness and adverse effects. Laryngoscope. 2009; 119(6):1241-1250.
3. Bican A, Kahraman A, Bora I, et al.  What is the efficacy of nasal surgery in patients with obstructive sleep apnea syndrome?  J Craniofac Surg. 2010; 21(6):1801-1806.  
4. Blumen MB, Chalumeau F, Gauthier A, et al. Comparative study of four radiofrequency generators for the treatment of snoring. Otolaryngol Head Neck Surg. 2008; 138(3):294-299.
5. Cavaliere M, Mottola G, Iemma M.  Monopolar and bipolar radiofrequency thermal ablation of inferior turbinates: 20-month follow-up. Otolaryngol Head Neck Surg. 2007; 137(2):256-263.
6. Ceylan K, Emir H, Kizilkaya Z, et al.  First-choice treatment in mild to moderate obstructive sleep apnea: single-stage, multilevel, temperature-controlled radiofrequency tissue volume reduction or nasal continuous positive airway pressure.  Arch Otolaryngol Head Neck Surg. 2009; 135(9):915-919.
7. Chen W, Kushida, CA. Nasal obstruction in sleep disordered breathing: Review article. Otolaryngol Clin North Ame. 2003; 36(3):437-460.
8. Franklin KA, Anttila H, Axelsson S, et al.  Effects and side-effects of surgery for snoring and obstructive sleep apnea—a systematic review. Sleep. 2009; 32(1):27-36.
9. Friedman M, Lin HC, Gurpinar B, Joseph NJ. Minimally invasive single-stage multilevel treatment for obstructive sleep apnea/hypopnea syndrome. Laryngoscope. 2007; 117(10):1859-1863.
10. Friedman M, Soans R, Joseph N, et al.  The effect of multilevel upper airway surgery on continuous positive airway pressure therapy in obstructive sleep apnea/hypopnea syndrome.  Laryngoscope. 2009; 119(1):193-196.
11. Friedman M, Tanyeri H, Lim JW, et al. Effect of improved nasal breathing on obstructive sleep apnea. Otolaryngol.Head Neck Surg. 2000; 122(1):71-74.
12. Gindros G, Kantas I, Balatsouras DG, et al.  Comparison of ultrasound turbinate reduction, radiofrequency tissue ablation and submucosal cauterization in inferior turbinate hypertrophy.  Eur Arch Otorhinolaryngol. 2010; 267(11):1727-1733.
13. Harrill WC, Pillsbury HC, McGuirt WF, Stewart MG. Radiofrequency turbinate reduction: a NOSE evaluation. Laryngoscope. 2007; 117(11):1912-1919.
14. Hytonen ML, Bäck LJ, Malmivaara AO, Roine RP. Radiofrequency thermal ablation for patients with nasal symptoms: a systematic review of effectiveness and complications. Eur Arch Otorhinolaryngol. 2009; 266(8):1257-1266.
15. Kizilkaya Z, Ceylan K, Emir H, et al. Comparison of radiofrequency tissue volume reduction and submucosal resection with microdebrider in inferior turbinate hypertrophy. Otolaryngol Head Neck Surg. 2008; 138(2):176-181.
16. Koutsourelakis I, Georgoulopoulos G, Perraki E, et al. Randomised trial of nasal surgery for fixed nasal obstruction in obstructive sleep apnoea. Eur Respir J. 2008; 31(1):110-117. author reply 246-247.
17. Li HY, Lin Y, Chen NH, et al. Improvement in quality of life after nasal surgery alone for patients with obstructive sleep apnea and nasal obstruction. Arch Otolaryngol Head Neck Surg. 2008; 134(4):429-433.
18. Li H, Wang PC, Chen YP, et al.  Critical appraisal and meta-analysis of nasal surgery for obstructive sleep apnea. Am J Rhinol Allergy. 2010 Dec. 17. 
19. Lin H, Friedman M, Chang H, et al. The efficacy of multilevel surgery of the upper airway in adults with obstructive sleep apnea/hypopnea syndrome. Laryngoscope. 2008; 118(5):902-908.
20. Masdon JL, Magnuson JS, Youngblood G. The effects of upper airway surgery for  obstructive sleep apnea on nasal continuous positive airway pressure settings. Laryngoscope. 2004; 114(2):205-207. 
21. Masood A, Phillips B. Radiofrequency ablation for sleep-disordered breathing. Curr Opin Pulm Med. 2001; 7(6):404-406.
22. Mirza N, Lanza DC. The nasal airway and obstructed breathing during sleep. Otolaryngol Clin North Am. 1999; 32(2):243-262.
23. Neace JM, Krempl GA. Radiofrequency treatment of turbinate hypertrophy, a randomized, blinded, placebo-controlled clinical trial. Otolarygnl Head Neck Surg. 2004; 130(3):291-299.
24. Nelson LM, Barrera JE. High energy single session radiofrequency tongue treatment in obstructive sleep apnea surgery. Otolaryngol Head Neck Surg. 2007; 137(6):883-888.
25. Olson EJ, Park JG, Morgenthaler TI.  Obstructive sleep apnea-hypopnea syndrome. Prim Care. 2005; 32(2):329-359.
26. Rappai M, CollopN, Kemp S, deShazo R. The nose and sleep-disordered breathing. what we know and what we do not know. Chest. 2003; 124(6):2309-2323.
27. Rhee CS, Kim DY, Won TB, et al. Changes of nasal function after temperature-controlled radiofrequency tissue volume reduction for the turbinate. Laryngoscope. 2001; 111(1):153-158.
28. Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep. 1996; 19(2):156-177.
29. Singh A, Patel N, Kenyon G, Donaldson G. Is there objective evidence that septal surgery improves nasal airflow? J Laryngol Otol. 2006; 120(11):916-920.
30. Steward DL. Effectiveness of multilevel (tongue and palate) radiofrequency tissue ablation for patients with obstructive sleep apnea syndrome. Laryngoscope. 2004; 114(12):2073-2084.
31. Stewart MG, Smith TL, Weaver EM, et al.  Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study.  Otolaryngol Head Neck Surg. 2004; 130(3):283-290.
32. Stuck BA, Sauter A, Hormann K, et al.  Radiofrequency surgery of the soft palate in the treatment of snoring.  A placebo controlled trial.  Sleep. 2005; 28(7):847-850.
33. Troell RJ.  Radiofrequency techniques in the treatment of sleep disordered breathing.  Otolaryngol Clin N Am. 2003; 36:473-493.
34. Verse T, Maurer JT, Pirsig W. Effect of nasal surgery on sleep-related breathing disorders. Laryngoscope. 2002; 112(1):64-68.
35. Weaver TE, Grunstein RR.  Adherence to continuous positive airway pressure therapy: the challenge to effective treatment.  Proc Am Thorac Soc. 2008; 5(2):173-178.
36. Zonato AI, Bittencourt LR, Martinho FL, et al.  Upper airway surgery: the effect on nasal continuous positive airway pressure titration on obstructive sleep apnea patients.  Eur Arch Otorhinolaryngol. 2006; 263(5):481-486.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Society of Plastic Surgeons (ASPS).  Practice parameter:  Nasal Surgery.  July 2006. Available at:  http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Nasal-Surgery-Practice-Parameter.pdf.  Accessed on June 25, 2012.
2. Aurora RN, Casey KR, Kristo D, et al.  American Academy of Sleep Medicine (AASM).  Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults.  Sleep. 2010; 33(10):1408-1413.  Available at:  http://www.aasmnet.org/Resources/PracticeParameters/PP_SurgicalModificationsOSA.pdf.  Accessed on June 25, 2012.
3. Epstein LJ, Kristo D, Strollo PJ, et al. American Academy of Sleep Medicine (AASM).  Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009; 5(3):263-276.  Available at: http://www.aasmnet.org/Resources/ClinicalGuidelines/OSA_Adults.pdf.  Accessed on June 16, 2012.
4. Institute for Clinical Systems Improvement (ICSI).  Health Care guideline:  Diagnosis and Treatment of Obstructive Sleep Apnea.  Bloomington, MN:  Institute for Clinical Systems Improvement (ICSI); Sixth Edition, June 2008.  Available at: http://www.icsi.org/sleep_apnea/sleep_apnea__diagnosis_and_treatment_of_obstructive_.html. Accessed on June 16, 2012.5.      
5. Main C, Liu Z, Welch K, et al.  Surgical procedures and non-surgical devices for the management of non-apnoeic snoring: a systematic review of clinical effects and associated treatment costs. Health Technol Assess. 2009; 13(3):iii, xi-xiv, 1-208.
6. National Institute for Health and Clinical Excellence (NICE). Interventional Procedures Guidance 36.  Radiofrequency volumetric tissue reduction for turbinate hypertrophy. January 2004. Available at: http://www.nice.org.uk/nicemedia/live/11126/31180/31180.pdf.  Accessed on June 16, 2012.
7. National Institute for Health and Clinical Excellence (NICE).  Interventional Procedure Guidance 124.  Radiofrequency ablation of the soft palate for snoring.  London, UK: NICE.  May 2005.  Available at:    http://www.nice.org.uk/nicemedia/live/11165/31358/31358.pdf.  Accessed on June 16, 2012.
8. Sundaram S, Bridgman SA, Lim J, Lasserson TJ.  Surgery for obstructive sleep apnoea in adults. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD001004. Last assessed as up to date July 1, 2008.  Available at:  http://www2.cochrane.org/reviews/en/ab001004.html.  Accessed on June 16, 2012.
9. Taichung Veterans General Hospital. Randomized Controlled Trial of TCRFVR and LAUP in  snorers.  Completed: March 2004. Last updated Sept. 13, 2005. Available at:  http://clinicaltrials.gov/show/NCT00202943.  Accessed on June 16, 2012.
10. U.S. Food and Drug Administration (FDA).  Center for Devices and Radiological Health Circulatory System Devices Panel.  Somnoplasty System^™  (Somnus Medical Technologies, Sunnyvale, CA).  Summary of Safety and Effectiveness.  No. K971450  July 17, 1997.  Available at:  http://www.accessdata.fda.gov/cdrh_docs/pdf/K971450.pdf.  Accessed on June 16, 2012.
11. U.S. Food and Drug Administration (FDA).  Center for Devices and Radiological Health Circulatory System Devices Panel.  Gyrus G I1 Radio-frequency Workstations (Gyrus Medical Inc., Bartlett, TN).  Summary of Safety and Effectiveness.  No. K021777  August 26, 2002.  Available at:  http://www.accessdata.fda.gov/cdrh_docs/pdf2/k021777.pdf.  Accessed on June 16, 2012.

1. American Academy of Sleep Medicine (AASM).  Available at: http://www.aasmnet.org/default.aspx.  Accessed on June 16, 2012.
2. American Academy of Otolaryngology- Head and Neck Surgery (AAO/HNS). Nasal surgery and OSAS.  May 3, 2010.   Available at:   http://www.entnet.org/Practice/Nasal-Surgery-and-OSAS.cfm. Accessed on June 16, 2012.

Nasal Turbinate Hypertrophy
Obstructive Sleep Apnea, Nasal Surgery for
Radiofrequency Ablation of Nasal Turbinates
Somnoplasty (Volumetric Tissue Reduction of Nasal Turbinates)
Volumetric Tissue Reduction of Nasal Turbinates