054 Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring

POLICY – MPP – 054 Nasal Surgery for the treatment of Obstructive Sleep Apnea and Snoring

Department/Team Medical Management/Medical Payment Policy (MPP) Approval By HQUM Approval Date 09/25/2020 Effective Date 09/01/2009 Line of Business ☒ CCC+ ☐ Exchange ☒ Medallion 4.0 ☒ D-SNP ☒ MAPD

PURPOSE This policy outlines guidelines and criteria for coverage determination of nasal surgery for the treatment of obstructive sleep apnea and snoring.

DESCRIPTION

Increased nasal resistance may contribute to sleep related breathing disorders such as obstructive sleep apnea. For this reason, nasal surgical procedures that have been performed for the treatment of OSA. These surgeries include nasal valve surgery, septal surgery (aka septoplasty), surgery to correct nasal turbinate hypertrophy or deformity (turbinectomy), and finally nasal polypectomy.

Radiofrequency ablation for chronic nasal obstruction with or without OSA has also been proposed. This volumetric tissue reduction surgery is performed most commonly on the inferior nasal turbinates, felt to be the most common origin of chronic nasal obstruction. During this procedure a needle electrode is placed into the anterior inferior turbinate, and radiofrequency energy is delivered. This results in a lesion that produces scarring and contraction of soft tissue, thereby reducing the volume of the turbinate and associated obstruction.

GUIDELINES/INSTRUCTIONS

SCOPE:

This policy specifically addresses any form of nasal surgery for the treatment of obstructive sleep apnea, including radiofrequency ablation.

POSITION:

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 Page 1 of 4

POLICY – MPP – 054 Nasal Surgery for the treatment of Obstructive Sleep Apnea and Snoring

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.

CODING:

When Services are Not Medically Necessary:

CPT 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)

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- Excision of nasal septum [by approach; includes codes 09BM0ZZ, 09BM3ZZ, 09BM4ZZ 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- Resection of nasal septum [by approach; includes codes 09TM0ZZ, 09TM4ZZ] 09TM4ZZ

ICD-10 Diagnosis ICD-10-CM draft codes; effective 10/01/2014: R06.83 Snoring

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POLICY – MPP – 054 Nasal Surgery for the treatment of Obstructive Sleep Apnea and Snoring

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.

ICD-10 ICD-10-CM draft codes; effective 10/01/2014: Diagnosis G47.30-G47.39 Sleep apnea G47.8 Other sleep disorders G47.9 Sleep disorder, unspecified

REFERENCES

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. Chen W, Kushida, CA. Nasal obstruction in sleep disordered breathing: Review article. Otolaryngolic Clinics of North America. 2003; 36(3):437-460. 3. Friedman M, et al. Effect of improved nasal breathing on obstructive sleep apnea. Otolaryngol.Head Neck Surg. 2000; 122(1):71-74. 4. Masood A, Phillips B. Radiofrequency ablation for sleep disordered breathing. Current Opinion Pulmonary Medicine. 2001; 7(6):404-406. 5. Mirza N, Lanza DC. The nasal airway and obstructed breathing during sleep. Otolaryngolic Clinics of North America. 1999; 32(2). 6. Neace JM, Radiofrequncy treatment of turbinate hypertrophy, a randomized, blinded, placebo controlled clinical trial. Oto Larygnl Head Neck Surg. 2004; 130(3):291-299. 7. Olson EJ, Park JG, Morgenthaler TI. Obstructive sleep apnea-hypopnea syndrome. Prim Care Clin Office Pract. 2005; 32:329-359. 8. Rappai M, et al. The nose and sleep disordered breathing. What we know and what we do not know. Chest. 2003; 124(6). 9. Rhee CS, et al. Changes of nasal function after temperature-controlled radiofrequency tissue volume reduction for the turbinate. Laryngoscope. 2001; 111(1):153-158. 10. Sher AE, et al. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. An American Sleep Disorders Review, Sleep. 1995; 18(8):659-666. 11. Steward DL. Effectiveness of multilevel (tongue and palate) radiofrequency tissue ablation for patients with obstructive sleep apnea syndrome. Laryngoscope. 2004; 114(12):2073-2084. 12. 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. 13. 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. 14. Troell RJ. Radiofrequency techniques in the treatment of sleep disordered breathing. Otolaryngol Clin N Am. 2003; 36:473-493. 15. Verse T, et al. Effect of nasal surgery on sleep-related breathing disorders. Laryngoscope. January 1, 2002; 112(1): 64-68. 16. https://www.anthem.com/medicalpolicies/guidelines/gl_pw_a051158.htm Accessed August 28,2020 17. http://www.aetna.com/cpb/medical/data/1_99/0004.html. Accessed August 28, 2020

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POLICY – MPP – 054 Nasal Surgery for the treatment of Obstructive Sleep Apnea and Snoring