Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Hypertrophied Turbinates.

Treatment: VivAer nasal airway reconstruction procedure.

The insurer denied coverage for VivAer nasal airway reconstruction procedure.

The denial is upheld.

This is the case of a male with long-standing sleep apnea and chronic nasal obstruction. Multiple sleep studies done in past all showing mild obstructive sleep apnea (OSA). History of multiple surgeries with continued symptoms of nasal obstruction. Referred for VivAer Procedure for nasal airway reconstruction period. This is a new procedure for which there is limited literature. It does appear to be an exciting procedure with great potential for the relief of symptomatic nasal obstruction. 

The following is taken from the VivAer Website.

The low profile VivAer Stylus employs transmucosal, temperature-controlled radiofrequency (RF) technology, optimized for the nasal airway. Once the stylus is inserted into the nose, the Aerin System automatically maintains the tip's target temperature for therapeutic benefit while sparing surrounding tissue, including mucosa.

VivAer enables you to effectively tackle many of the core causes of nasal airway obstruction with one treatment:

1) Durably remodels nasal cartilage and soft tissue
2) Single solution that treats the entire nasal valve, including lateral wall, inferior turbinate, and septal swell body: 1) Increases nasal valve radius to improve airflow. 2)Shrinks submucosal tissue of the inferior turbinate. 3)Reduces soft tissue obstruction on the septum.

The patient is highly symptomatic in reference to both symptomatic nasal obstruction and sleep apnea. He has failed many other procedures and it seems like a very reasonable intervention regarding the nasal obstruction symptoms. There is certainly preliminary data to support it's used with documented relief of symptoms using a well-defined symptom scoring pattern.

There appears to be no literature regarding treating sleep apnea using this intervention. Intuitively it would seem to help especially in a patient who already underwent procedures for the back of the airway uvulopalatopharyngoplasty (UPPP) and tonsillectomy. However nasal procedures have generally not been found to be particularly helpful in the management of sleep apnea patients. 
The following is a quote from UpToDate

"Nasal surgery as a stand-alone procedure does not reliably treat OSA. Evidence of the benefit of nasal surgery as an adjunctive procedure consists primarily of observational series.  A systematic review of the effect of isolated nasal surgery on continuous positive airway pressure (CPAP) device use and therapeutic pressures identified 18 studies in 279 patients. In seven studies (82 patients) that reported baseline and postoperative device pressure settings, nasal surgery reduced mean CPAP therapeutic pressure from 12 to 10 centimeters of water pressure. Clinical outcomes were variably reported; in a subgroup analysis of 11 studies that included self-reported data on CPAP use, 89 percent of 64 patients who were not using CPAP before surgery were subsequently able to accept, adhere to, or tolerate CPAP after surgery."

This patient has actually undergone multiple procedures already so perhaps one would consider this intervention a form of adjunctive therapy or additive therapy rather than an independent treatment.

The patient is not a good candidate for VivAer nasal airway reconstruction procedure. It is not the best available treatment for this patient at this time. 
The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.
The carrier's denial of VivAer nasal airway reconstruction procedure should be upheld.