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 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. 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

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 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.

BlueCross BlueShield Association. Evidence Positioning System. (7:2019). Surgical treatment of snoring and obstructive sleep apnea syndrome. (7.01.101). Retrieved August 29, 2019 from https://www.evidencepositioningsystem.com/. (30 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  6/1/2000

MOST RECENT REVIEW DATE:  10/10/2019

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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