Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a 33-year-old male with obstructive sleep apnea. He was prescribed a trial of nasal CPAP, but has had difficulty sleeping with this for longer than three hours a night. He noted that his nasal passages are quite obstructed. Examination previously had revealed the presence of engorged inferior turbinates and the patient did undergo a trial of Nasonex nasal spray. As the patient was failing in his trial of CPAP and had failed a trial of medical therapy for his nasal congestion, turbinoplasty was undertaken. The method chosen for this procedure was radiofrequency ablation. According to the surgeons notes, this procedure was performed in treatment of hypertrophy of the inferior turbinates. The patient was also referred for evaluation for the creation of a dental appliance for further treatment of his sleep apnea. The Health Plan has denied reimbursement for radiofrequency turbinate reduction on the basis the procedure is considered investigational for treatment of the patients condition.Nasal airway restriction is a fairly common cause of CPAP noncompliance and inferior turbinate hyperplasia is a common cause of nasal airway restriction. There are multiple methods by which to reduce the size of inferior turbinates. These range from scissors resection of a portion of the turbinate to submucosal resection to cautery/heat reduction. This latter method has included the use of unipolar electrocautery, laser and radiofrequency devices.Over the past six years the literature regarding radiofrequency reduction of the inferior turbinates in the treatment of nasal airway obstruction has increased exponentially and this procedure appears to be becoming a standard of care. Outcomes have shown to be good, post-operative discomfort is decreased and, if desired, this procedure may be performed in the outpatient setting. Unipolar submucosal ablation of turbinates has been used for many years. Bipolar radiofrequency ablation is simply a less destructive method for doing this same procedure. The coblation device has been FDA approved for this purpose since October 2003. This patient underwent radiofrequency reduction of the inferior turbinates for the purpose of improving the nasal airway. Review of the surgeon's notes demonstrates this was done in order to assist the patient in using the CPAP device, not to try to cure him of his sleep apnea. Given the above reasoning and the widespread acceptance and ongoing use of the radiofrequency devices, the Health Plan should provide reimbursement for this procedure.Based upon the information set forth above, I have determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 33-year-old male with a history of objective documented obstructive sleep apnea with a RDI of 41 events per hour of sleep. The patient was being treated with CPAP, but having some difficulties with this secondary to nasal obstruction, judged to be secondary to hypertrophic turbinates. The patients provider recommended radiofrequency reduction of inferior turbinates, which the patient underwent in June 2005. The Health Plan has denied coverage for radiofrequency turbinate reduction indicating the efficacy of the procedure has not been established.The Health Plans denial should be upheld. Review of the relevant medical literature does not demonstrate radiofrequency turbinate reduction has superior efficacy to standard forms of treatment. There were other treatment modalities available that were likely to be effective for this patients condition. Based upon the information provided, it does not appear the patient exhausted conservative therapies. As such, I have determined the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 33-year-old male who has moderate to severe obstructive sleep apnea (OSA) and nasal obstruction (not responding to nasal steroids). He failed a trial of CPAP therapy for some unspecified reason. The patients provider recommended the patient undergo radiofrequency turbinate reduction. The Health Plan has denied reimbursement for this procedure citing a lack of proven efficacy.Reduction of the nasal obstruction is beneficial in the treatment of OSA as an adjuvant to definitive therapy. It will not resolve the OSA but can help make the use of CPAP more tolerable with a patient's nasal airway. Radiofrequency tissue reduction is a well-tolerated means of reducing the tissue volume at multiple sites (nasal turbinates, soft palate, and tongue base). It is just a different technique compared to turbinectomy. It is essentially the same as tissue reduction using cautery but has lower morbidity, i.e., less pain, less edema, faster healing.Radiofrequency is not approved for the treatment of OSA but is a very effective technique for treating nasal obstruction. Reducing the nasal obstruction is medically warranted as an adjunctive therapy to the definitive treatment for OSA (i.e., repeat trial CPAP or dental appliance or UPPPP). Radiofrequency reduction of the turbinate is an effective treatment with reduced side effects to the patient and is acceptable and preferred by many ENT surgeons.  Based upon the information set forth above, I have determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.