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) utilizes low-power, low-temperature radiofrequency energy in the treatment of obstructive sleep apnea. The objective of radiofrequency tissue volume reduction (RFTVR) is to decrease the amount of redundant tissue in the soft palate, tongue, turbinates and tonsils. 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. The tissue volume is reduced and the area that is responsible for causing the obstructive sleep apnea stiffens. In some instances radiofrequency tissue volume reduction may need to be repeated depending on the severity of the individual's condition.

POLICY

Radiofrequency tissue volume reduction for the treatment of upper airway obstruction is considered investigational.

See also:

IMPORTANT REMINDERS

Any specific products referenced in this policy are just examples and are intended for illustrative purposes 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. These examples are contained in the parenthetical e.g. statement.

We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

ADDITIONAL INFORMATION

Studies in peer-reviewed literature are lacking regarding whether RFVTR is as beneficial as medical management or other surgical procedures for the treatment of upper airway obstruction.

SOURCES

BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2011). Surgical treatment of snoring, obstructive sleep apnea syndrome. (7.01.101). Retrieved September 27, 2011 from BlueWeb. (30 articles and/or guidelines reviewed)

Holty, J., Guilleminault, C. (2010) Surgical options for the treatment of obstructive sleep apnea. Medical Clinics of North America, 94 (3), 479-515.

Powell, N. B., Riley, R. W., & Guileminault, C. (1999). Radiofrequency tongue base reduction in sleep-disordered breathing: A pilot study. Otolaryngology-Head and Neck Surgery, 120 (5), 656-664. (Level 4 Evidence – Industry Supported)

U. S. Food and Drug Administration. (2000). Center for Devices and Radiological Devices. 510(k) Premarket Notification Database. K971450. Retrieved September 28, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf/K971450.pdf.

Winifred S. Hayes. Medical Technology Directory. (2005, September, last update search October, 2009 - Archived). Sleep apnea treatment, surgical. Retrieved December 11 2009 from http://www.Hayesinc.com/subscribers. (77 articles and/or guidelines reviewed)

Winifred S. Hayes. Medical Technology Directory. (2007, March, last update search March, 2011). Radiofrequency tissue volume reduction for the treatment of upper airway obstruction. Retrieved September 27, 2011 from http://www.Hayesinc.com/subscribers. (76 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE: 6/1/2000

MOST RECENT REVIEW DATE: 11/10/2011

ID_BA

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.

This document has been classified as public information.