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.
Standard surgical procedures (i.e., uvulopalatopharyngoplasty [UPPP] and maxillofacial procedures) have been found to improve symptoms in adults with clinically significant obstruction. Minimally invasive surgical procedures have limited efficacy with mild-to-moderate OSA and have not been shown to improve Apnea/Hypoxia Index or excessive daytime sleepiness in adults with moderate to severe OSA.
POLICY
Radiofrequency volumetric tissue reduction of the tongue and/or palatal tissues, for the treatment of obstructive sleep apnea or upper airway obstruction, is considered investigational.
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 or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
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 Pediatrics. (2012). Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics, 130 (3), e714-e755. Retrieved August 29, 2019 from https://pediatrics.aappublications.org/content/pediatrics/130/3/e714.full.pdf.
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. Retrieved March 14, 2023 from https://aasm.org/?s=Practice+parameters+for+the+surgical+modifications+of+the+upper+airway+for+obstructive+sleep+apnea+in+adults.
Bäck, L.J., Liukko, T., Rantanen, I., Peltola, J.S., Partinen, M., Ylikoski, J., et al. (2009). Radiofrequency surgery of the soft palate in the treatment of mild obstructive sleep apnea is not effective as a single-stage procedure: A randomized single-blinded placebo-controlled trial. Laryngoscope,119 (8), 1621-1627. Abstract retrieved April 7, 2021 from PubMed data base.
BlueCross BlueShield Association. Evidence Positioning System. (7:2022). Surgical treatment of snoring and obstructive sleep apnea syndrome. (7.01.101). Retrieved March 13, 2023 from https://www.evidencepositioningsystem.com/. (36 articles and/or guidelines reviewed)
ORIGINAL EFFECTIVE DATE: 6/1/2000
MOST RECENT REVIEW DATE: 5/11/2023
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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