BlueCross BlueShield of Tennessee Medical Policy Manual

Radiofrequency Tissue Volume Reduction (RFTVR) for the Treatment of Upper Airway Obstruction

DESCRIPTION

Radiofrequency tissue volume reduction (e.g., Somnoplasty® device) is a minimally invasive procedure that utilizes low-power, low-temperature radiofrequency energy to produce thermal lesions in the soft palate and base of the tongue as a treatment of obstructive sleep apnea (OSA). The objective of radiofrequency tissue volume reduction is to decrease the amount of redundant tissue. The procedure is performed in the physician's office using local anesthesia and takes approximately thirty minutes to complete. By means of a partially insulated electrode, radiofrequency energy is delivered into the area through the submucosal tissue to make one or several coagulation lesions. The treated tissue is naturally absorbed over the next four to eight weeks.

Obstructive sleep apnea syndrome is characterized by repetitive episodes of upper airway obstruction due to the collapse of the upper airway during sleep. Standard surgical procedures (i.e., uvulopalatopharyngoplasty [UPPP] and maxillofacial procedures) have been found to improve symptoms in adult patients with clinically significant. Minimally invasive surgical procedures have limited efficacy in patients with mild-to-moderate OSA and have not been shown to improve Apnea/Hypoxia Index or excessive daytime sleepiness in adult patients with moderate to severe OSA. Additional study is needed to determine whether adding minimally invasive procedures to UPPP improves the net health outcome compared with treatment with UPPP alone.

POLICY

See also:

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Studies in peer-reviewed literature are lacking to determine if radiofrequency tissue volume reduction is as beneficial as medical management or other surgical procedures for the treatment of upper airway obstruction.

SOURCES

American Academy of Sleep Medicine (2010). Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep, 33 (10), 1408-1413.

American College of Physicians (2013) Management of obstructive sleep apnea in adults: a clinical practice guideline from the american college of physicians. Annals of Internal Medicine, (159), 471-483.

BlueCross BlueShield Association. Medical Policy Reference Manual. (9:2017). Surgical treatment of snoring and obstructive sleep apnea syndrome. (7.01.101). Retrieved November 15, 2017 from BlueWeb. (32 articles and/or guidelines reviewed)

California Technology Assessment Forum/ Institute for Clinical and Economic Review. (2013, January) Diagnosis and treatment of obstructive sleep apnea in adults. Retrieved November 15, 2017 from https://icer-review.org/materials.

Caples, S., Rowley, J., Prinsell, J., Pallanch, J., Elamin, M., Katz, S., et al. (2010). Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep, 33 (10), 1396-1407. (Level 1 evidence)

Holty, J., and Guilleminault (2010) Surgical options for the treatment of obstructive sleep apnea. Medical Clinics of North America; 94:179-515. (Level 1 evidence)

Kim, R., Dedhia, R., and Kapur, V. (2015, March) Does surgery for obstructive sleep apnea provide value? Journal of Clinical Sleep Medicine, Vol. 11; No. 5, 509-10. (Level 5 evidence)

U. S. Food and Drug Administration. (2002). Center for Devices and Radiological Devices. 510(k) Premarket Notification Database. K020778.(Somnoplasty®) Retrieved May 28, 2013 from http://www.accessdata.fda.gov.

Wisconsin Physicians Service, Inc. (2017, January) Local Coverage Determination (LCD): Surgical treatment of obstructive sleep apnea (OSA) (L34526). Retrieved November 15, 2017 from: https://www.cms.gov.   

Xiao, S. and Zang, J. (2015, March) Redefine the efficacy of surgical treatments for obstructive sleep apnea hypopnea syndrome.MedLine, 29 (6), 192-4. Abstract retrieved December 1, 2016 from PubMed database.

ORIGINAL EFFECTIVE DATE:  6/1/2000

MOST RECENT REVIEW DATE:  12/14/2017

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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