Clinical UM Guideline |
Subject: Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring | |
Guideline #: CG-SURG-87 | Publish Date: 10/01/2024 |
Status: Reviewed | Last Review Date: 08/08/2024 |
Description |
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:
Clinical Indications |
Not Medically Necessary:
Nasal surgery employing any technique is considered not medically necessary for the treatment of snoring.
Nasal surgery employing any technique is considered not medically necessary for the treatment of obstructive sleep apnea and other sleep related breathing disorders.
Coding |
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. 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:
For the following procedure and diagnosis codes or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.
CPT |
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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 (eg, 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 (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); superficial |
30802 | Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (ie, submucosal) |
31237 | Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) |
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ICD-10 Procedure | |
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] |
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ICD-10 Diagnosis | |
G47.30-G47.39 | Sleep apnea |
G47.8 | Other sleep disorders |
G47.9 | Sleep disorder, unspecified |
R06.83 | Snoring |
Discussion/General Information |
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 indicators for obstructive sleep apnea (OSA), 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.
In a Cochrane review, Rimmer and colleagues (2014) found:
The evidence relating to the effectiveness of different types of surgery versus medical treatment for adults with chronic rhinosinusitis with nasal polyps is of very low quality. The evidence does not show that one treatment is better than another in terms of patient-reported symptom scores and quality of life measurements. The one positive finding from amongst the several studies examining a number of different comparisons must be treated with appropriate caution, in particular when the clinical significance of the measure is uncertain. As the overall evidence is of very low quality (serious methodological limitations, reporting bias, indirectness and imprecision) and insufficient to draw firm conclusions, further research to investigate this problem, which has significant implications for quality of life and healthcare service usage, is justified.
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. 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).
In a review, Bury and colleague (2015) found that snoring and obstructive sleep apnea have been well researched. While the studies supporting nasal surgery for snoring can improve the quality of life, it may not lead to the resolution of snoring. Likewise, compliance with nasal treatments for OSA may increase the quality of life in some individuals. Further well-designed studies are needed to clarify the role of nasal surgery in OSA, with stratification of individuals who may benefit from nasal intervention.
The American Academy of Otolaryngology—Head and Neck Surgery Foundation (2015) published a clinical consensus statement addressing: Septoplasty with or without Inferior Turbinate Reduction. Utilizing the Delphi Method, a panel of specialists considered eight areas, one of which was surgical, addressing septoplasty. Based on an anonymous survey response, the panel reached consensus stating that:
Well-designed, randomized studies are necessary to define appropriate criteria for OSA surgical procedures.
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, but are not limited to the following:
Definitions |
Chronic: Refers to persistent conditions with symptoms that last over a long period of time.
Delphi Method: A structured communication technique or method originally developed as a systematic, interactive forecasting method which relies on a panel of experts. The experts answer questionnaires in two or more rounds.
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.
Snoring: A fluttering sound created by the turbulent airflow vibrations of upper airway soft tissue during sleep.
Somnoplasty® (also referred to as radiofrequency ablation [RFA] or radiofrequency volumetric tissue reduction [RFVTR]): 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.”
References |
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Websites for Additional Information |
Index |
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
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
History |
Status | Date | Action |
Reviewed | 08/08/2024 | Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References and Websites for Additional Information. |
Reviewed | 08/10/2023 | MPTAC review. Updated References and Websites for Additional Information. |
Revised | 08/11/2022 | MPTAC review. Information related to absorbable nasal implant (Latera) and nasal valve surgery moved to SURG.00079 Nasal Valve Repair. Updated Description, Rationale, References, Websites for Additional Information, Index and History sections. Updated Coding section to remove CPT code 30468 now addressed in SURG.00079. |
Reviewed | 05/13/2021 | MPTAC review. Definitions and References were updated. Reformatted Coding section; removed 30999 no longer applicable. |
| 12/16/2020 | Updated Coding section with 01/01/2021 CPT and HCPCS changes; added 30468, code C9749 deleted 12/31/2020. |
Reviewed | 05/14/2020 | MPTAC review. References were updated. |
Reviewed | 06/06/2019 | MPTAC review. The Discussion and References sections were updated. |
New | 07/26/2018 | MPTAC review. Moved content of SURG.000074 Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring to new clinical utilization management guideline document with the same title. Removed acronym (OSA) from the title. The References section was updated. |
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