Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Nasal value collapse. 
Treatment: Repair of Nasal Valve Collapse with Low Energy, Temperature Controlled (radiofrequency- code 30469). 

The insurer denied: Repair of Nasal Valve Collapse with Low Energy, Temperature Controlled (radiofrequency- code 30469). 

The denial is upheld.

The patient is an adult male with a history of nasal obstruction, sleep disturbance including obstructive sleep apnea and sleep-disordered breathing (snoring). The patient also has a history of ear cerumen, Meniere's Disease per clinical documentation and bilateral sensorineural hearing loss. A physical examination revealed a caudal septal deviation, stenosis of the nasal valve, enlarged swell bodies and bilateral turbinate hypertrophy. Evidence of acute sinusitis was also evidenced four months ago. A course of antibiotics was recommended (cefuroxime). Given the examination findings, an in-office active treatment of the nasal valve with a temperature-controlled radiofrequency (TCRF) was recommended. A home sleep study for the patient's history of snoring was recommended. Allergy testing was completed four months ago. An MRI (magnetic resonance imaging) was completed for asymmetry in the patient's hearing. The at-home sleep test indicated severe obstructive sleep apnea. The request to perform treatment of the nasal valve with a temperature-controlled radiofrequency (TCRF) was denied. A request for an internal appeal was filed. An internal appeal was completed with the denial upheld. 

The health plan should not cover the requested health service. 

There are limited objective data available in the literature, including randomized controlled trials, to support that treatment of the nasal valve with a temperature-controlled radiofrequency (TCRF) is more beneficial than any standard treatment. As of the writing of this report, there is insufficient evidence to support that treatment of the nasal valve with a temperature-controlled radiofrequency (TCRF) is equivalent to operative repair of the nasal valve. The nasal valve area is formed by the nasal septum, the caudal border of the ULC (upper lateral cartilage), the head of the inferior turbinate, and the pyriform aperture and the tissues that surround it. Therapeutic management of symptoms arising from anatomic aberrations of any/or all of these structures would involve addressing the involved structures surgically. Targeted low energy radiofrequency heating to the nasal sidewall to gently reshape the tissues has been purported to be helpful in addressing anomalies nasal valve responsible for nasal obstruction. The "Vivaer system," specifically, works via using targeted low-energy radiofrequency to heat and reshape the tissues of internal nasal valve to create more space in the nose. Some objective data published in the literature is suggestive of patient benefit (See Han et al., Ephrat et al., Brehmer et al. below). The gold standard for addressing disorders of the nasal valve, the cartilages in particular, is functional septo-rhinoplasty. This procedure involves operative remodeling of the cartilagenous structures of the nasal valve to mitigate anatomic deficiencies thought to produce symptoms such as nasal congestion and/or impaired nasal breathing. 
It is unknown in the clinical documentation provided as to which structures of the nasal valve are implicated in the genesis of the patient's symptoms. Without knowing which structures are implicated, the applicability of treatment of the nasal valve with a temperature-controlled radiofrequency (TCRF) versus functional septo-rhinoplasty cannot be assessed.