|Subject:||Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring|
|Policy #:||SURG.00074||Current Effective Date:||10/08/2013|
|Status:||Reviewed||Last Review Date:||08/08/2013|
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:
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, (for example, septoplasty, turbinectomy, polypectomy, radiofrequency volumetric tissue reduction [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 2013) 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), in which the authors 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:
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.
Somnoplasty® (also referred to as radiofrequency ablation or radiofrequency volumetric tissue reduction): These terms refer to a minimally invasive surgical procedure that reduces the excess volume of the surrounding tissues in the upper airway, in order to enlarge the space. These procedures have been purported to reduce the symptoms of OSA and snoring. Although the procedure has been used to remove tissue from the turbinates and tonsils, recent studies of RFA in the treatment of OSA have limited the procedure to the soft palate, uvula and tongue base. The Somnoplasty® System (Somnus Medical Technologies, Sunnyvale, CA) received clearance from the U.S. Food and Drug Administration (FDA) on July 17, 1997 for coagulation of soft tissue, including the uvula/soft palate. The 510(k) summary states that, "The Somnoplasty system may reduce the severity of snoring in some individuals." An expanded approval on November 2, 1998 states that, "The system is intended for the reduction of the incidence of airway obstruction in patients with upper airway resistance syndrome and OSA."
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:
|30110||Excision, nasal polyp(s), simple|
|30115||Excision, nasal polyp(s), extensive|
|30130||Excision inferior turbinate, partial or complete, any method|
|30140||Submucous resection inferior turbinate, partial or complete, any method|
|30465||Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)|
|30520||Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft|
|30801||Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (e.g., electrocautery, radiofrequency ablation, or tissue volume reduction); superficial|
|30802||Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (e.g., electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (i.e., submucosal)|
|31237||Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure)|
|21.31||Local excision or destruction of intranasal lesion (nasal polypectomy)|
|21.5||Submucous resection of nasal septum|
|21.61||Turbinectomy by diathermy or cryosurgery|
|786.09||Dyspnea and respiratory abnormalities, other [when specified as snoring]|
|ICD-10 Procedure||ICD-10-PCS draft codes; effective 10/01/2014:|
|095K0ZZ-095KXZZ||Destruction of nose [by approach; includes codes 095K0ZZ, 095K3ZZ, 095K4ZZ, 095KXZZ]|
|095L0ZZ-095L8ZZ||Destruction of nasal turbinate [by approach; includes codes 095L0ZZ, 095L3ZZ, 095L4ZZ, 095L7ZZ, 095L8ZZ]|
|09BK0ZZ-09BKXZZ||Excision of nose [by approach; includes codes 09BK0ZZ, 09BK3ZZ, 09BK4ZZ, 09BKXZZ]|
|09BL0ZZ-09BL8ZZ||Excision of nasal turbinate [by approach; includes codes 09BL0ZZ, 09BL3ZZ, 09BL4ZZ, 09BL7ZZ, 09BL8ZZ]|
|09BM0ZZ-09BM4ZZ||Excision of nasal septum [by approach; includes codes 09BM0ZZ, 09BM3ZZ, 09BM4ZZ]|
|09DL0ZZ-09DL8ZZ||Extraction of nasal turbinate [by approach; includes codes 09DL0ZZ, 09DL3ZZ, 09DL4ZZ, 09DL7ZZ, 09DL8ZZ]|
|09TL0ZZ-09TL8ZZ||Resection of nasal turbinate [by approach; includes codes 09TL0ZZ, 09TL4ZZ, 09TL7ZZ, 09TL8ZZ]|
|09TM0ZZ-09TM4ZZ||Resection of nasal septum [by approach; includes codes 09TM0ZZ, 09TM4ZZ]|
|ICD-10 Diagnosis||ICD-10-CM draft codes; effective 10/01/2014:|
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.
|327.20-327.29||Organic sleep apnea|
|780.51||Insomnia with sleep apnea, unspecified|
|780.53||Hypersomnia with sleep apnea, unspecified|
|780.57||Unspecified sleep apnea|
|ICD-10 Diagnosis||ICD-10-CM draft codes; effective 10/01/2014:|
|G47.8||Other sleep disorders|
|G47.9||Sleep disorder, unspecified|
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Web Sites for Additional Information|
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
|Reviewed||08/08/2013||Medical Policy & Technology Assessment Committee (MPTAC) review. No change to stance. The Definitions and References were updated.|
|Reviewed||08/09/2012||MPTAC review. No change to stance. The Rationale and References were updated.|
|Revised||08/18/2011||MPTAC review. The additional position statement regarding radiofrequency ablation of nasal turbinates was removed. The title has been changed from: Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) (Including Radiofrequency Ablation of Nasal Turbinates for Nasal Obstruction with or without OSA) to the following: Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring. The Description, Rationale, References and Coding sections were updated.|
|Reviewed||08/19/2010||MPTAC review. No change to stance. The Rationale and References were updated.|
|01/01/2010||Updated Coding section with 01/01/2010 CPT changes.|
|Reviewed||08/27/2009||MPTAC review. No change to stance. References were updated.|
|Revised||08/28/2008||MPTAC review. No change to stance. The position statement regarding radiofrequency ablation (volumetric tissue reduction) of nasal turbinates was clarified to consider these procedures as investigational and not medically necessary for all indications. References and Coding sections were updated.|
|02/21/2008||The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.|
|Reviewed||08/23/2007||MPTAC review. No change to stance. References were updated.|
|Reviewed||09/14/2006||MPTAC review. No change to stance. References were updated.|
|Revised||09/22/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
Last Review Date
|No prior document|
|WellPoint Health Networks, Inc.|
|3.03.27||Nasal Surgery for the treatment of Obstructive Sleep Apnea (OSA) (Including Radiofrequency Ablation of Nasal Turbinates for Nasal Obstruction with or without OSA)|