Mountain State Medical Policy Bulletin

Section: Surgery
Number: S-136
Topic: Radiofrequency Ablation of the Nasal Turbinates
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 07/2005

General Policy Guidelines

Indications and Limitations of Coverage

Radiofrequency ablation of the nasal turbinates is eligible for reimbursement when performed for the purpose of reducing hypertrophy of nasal turbinates (478.0).

Patients treated surgically with radiofrequency ablation of the turbinates should have a history of incomplete or failed conventional medical management documented in their medical records.

Occasionally, it may be necessary to repeat this service in patients who experience incomplete relief of their symptoms. It should not be necessary to repeat the procedure more often than once within a twelve-month period of time for a total of two treatments. Claims reporting a third treatment with radiofrequency ablation should be referred to a medical advisor for a medical necessity determination.  Services denied on the basis of medical necessity are nonbillable by participating, preferred, or network providers.

NOTE:
Refer to Medical Policy Bulletin Z-8 for guidelines on Radiofrequency Ablation of the palate and/or tongue base for the treatment of obstructive sleep apnea.

Description

Radiofrequency tissue ablation, procedure code 30802, is a surgical procedure that uses radiofrequency energy to heat and destroy submucosal tissue resulting in the reduction of tissue volume. Radiofrequency ablation of the turbinates (somnoplasty of the turbinates) is performed to relieve nasal obstruction that is secondary to inferior turbinate hypertrophy. Over a period of three to six weeks following the procedure, the body naturally absorbs the ablated tissue resulting in partial or complete relief of nasal congestion.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

30802     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

04/2000, Radiofrequency ablation of nasal turbinates

References

Nasal Turbinate Somnoplasty: Utilization of Radiofrequency to Treat Chronic Nasal Obstruction and Congestion, ACOMS, 1999

Radiofrequency bipolar submucosal diathermy of the inferior turbinates, American Journal of Rhinology, Vol. 13, No. 2, March-April 1999

Radiofrequency Energy Tissue Ablation for the Treatment of Nasal Obstruction Secondary to Turbinate Hypertrophy, Laryngoscope, Vol.109, May 1999

Radiofrequency Thermoablation of the Inferior Turbinate in Nasal Obstruction, COSM, 1999

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Glossary





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.