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    v1.0.31
    OpenPayerPolicy UpdatesOtorhinolaryngology (ENT)AmeriHealth Caritas VIP Latera Update | OpenPayer
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    CurrentAmeriHealth Caritas VIP CarePolicy CCP.1441

    Latera Absorbable Nasal Implant

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    This policy governs coverage of the Latera absorbable nasal implant for adults with symptomatic nasal airway obstruction caused by nasal valve collapse. Coverage is medically necessary only when specified clinical criteria are met; cosmetic and other uses are investigational or not medically necessary.

    Policy Summary
    PayerAmeriHealth Caritas VIP Care
    PolicyLatera Absorbable Nasal Implant
    Policy CodePolicy CCP.1441
    Change TypeRevised
    Effective DateFebruary 1, 2020
    Last ReviewFeb 1, 2026
    Next Review DateJune 1, 2027
    Key ActionDocument age, NOSE score of at least 55, positive Modified Cottle Maneuver, appropriate anatomy, and failure of at least four weeks of conservative management.
    SourceLink
    POLICY UPDATE CHANGES

    In 2025, coverage was modified to consider the Latera absorbable nasal implant medically necessary based on guideline recommendations and randomized controlled trial evidence.

    In 2026, the policy references were updated without a policy change.

    18+Minimum member age

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    ≥55
    Required NOSE score
    ≥4 weeksConservative management trial
    24 monthsDurable results described
    30468Related CPT code

    Medical Necessity and Exclusions

    Medically necessary Latera implantation

    Covered as medically necessary when ALL of the following are met:

    Initial coverage criteria

    • Member age: Member is age 18 or older.≥18 years
    • Severity: Nasal Obstruction Symptom Evaluation (NOSE) score is at least 55.NOSE ≥55
    • Objective nasal wall insufficiency: Dynamic bilateral nasal wall insufficiency is confirmed by a Positive Modified Cottle Maneuver.Positive Modified Cottle Maneuver
    • Anatomy: Nasal and facial anatomy is appropriate to receive the Latera implant.
    • Conservative treatment failure: There is documented failure of benefit after at least four weeks of conservative medical management.≥4 weeks

    Contraindications

    Not medically necessary or contraindicated when ANY of the following applies:

    Contraindications and non-covered circumstances

    • Anesthesia or procedure limitations: The member is unable to tolerate or is not a candidate for procedures performed under local anesthesia; requires or is anticipated to require another concurrent nasal procedure outside the index procedure within 12 months after the index procedure; or underwent functional endoscopic sinus surgery, sinuplasty, septoplasty, inferior turbinate reduction, or rhinoplasty within the previous six months.
    • Medication or reproductive status: The member is using chronic systemic steroids or recreational intranasal drugs; is known or suspected to be pregnant; or is lactating.
    • Treatment-area disease or healing risk: The member has an inflammatory or infectious condition or unhealed wound in the treatment area; cancerous or precancerous nasal lesions; prior radiation in the treatment area; current chemotherapy; a history of significant healing disorders, including hypertrophic scarring or keloid formation; poorly controlled diabetes mellitus; or a known or suspected allergy to materials in the Latera implant.

    All other uses of the Latera absorbable nasal implant, including use solely for cosmetic reasons, are considered investigational or not clinically proven.

    Use of the implant solely for cosmetic reasons, or for any other indication that does not meet the covered indication and clinical criteria, is not medically necessary.

    Coding and Operational Thresholds

    Related CPT CodeCPT
    30468Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s)
    Member age
    Minimum ageMember must be 18 years or older.
    Covered indicationTreatment of symptomatic nasal airway obstruction caused by nasal valve collapse.
    Required anatomyNasal and facial anatomy must be appropriate to receive the Latera implant.
    Nasal Obstruction Symptom Evaluation score
    Required NOSE scoreNasal Obstruction Symptom Evaluation (NOSE) score must be at least 55.
    Measure typeThe NOSE score is a validated patient-reported measure of nasal obstruction severity.
    Evidence population

    Documentation and Denial Risks

    Documentation Required

    Medical Necessity Documentation

    Document that the member is 18 years or older and has symptomatic nasal airway obstruction caused by nasal valve collapse. The record should include the NOSE score, qualifying examination findings, appropriate nasal and facial anatomy, and failure of benefit after at least four weeks of conservative medical management.

    • NOSE score ≥ 55.
    • Dynamic bilateral nasal wall insufficiency confirmed by a positive Modified Cottle Maneuver.
    • Document anatomy appropriate for the Latera implant and the specific symptoms attributable to nasal valve collapse.
    Documentation Required

    Complete Contraindication Screening

    Before requesting coverage, document a contraindication review addressing anesthesia candidacy, nasal procedure timing, relevant medications, and intranasal drug use. The member must be an appropriate candidate for the index procedure and have no applicable exclusion.

    • Confirm the member can tolerate and is a candidate for a procedure performed under local anesthesia.

    Clinical Background

    Nasal valve obstruction may result from structural or inflammatory conditions, including nasal sidewall or nasal valve collapse, septal deviation, and turbinate hypertrophy. These conditions can narrow or compromise the nasal airway and contribute to symptomatic nasal obstruction.

    Policy Definitions

    Dynamic bilateral nasal wall insufficiency
    ConditionDynamic bilateral insufficiency of the nasal wall.
    ConfirmationThe condition is confirmed by improvement or stabilization with the Positive Modified Cottle Maneuver.
    Coverage relevanceDynamic bilateral nasal wall insufficiency is required for covered Latera implantation.
    Nasal Obstruction Symptom Evaluation (NOSE) score
    DefinitionThe NOSE score is a validated patient-reported measure of nasal obstruction severity.
    Coverage thresholdA score of at least 55 is required for coverage.
    Clinical context
    Policy Summary
    PayerAmeriHealth Caritas VIP Care
    PolicyLatera Absorbable Nasal Implant
    Policy CodePolicy CCP.1441
    Change TypeRevised
    Effective DateFebruary 1, 2020
    Last ReviewFeb 1, 2026
    Next Review DateJune 1, 2027
    Key ActionDocument age, NOSE score of at least 55, positive Modified Cottle Maneuver, appropriate anatomy, and failure of at least four weeks of conservative management.
    SourceLink
    On This Page
    Medical Necessity and ExclusionsCoding and Operational ThresholdsDocumentation and Denial RisksClinical BackgroundPolicy Definitions
  1. Existing implant or dilator: The member has a permanent nasal implant of any type, including an autologous, homologous, or synthetic graft, or has a nasal dilator.
  2. Severe obstructive sleep apnea: The member has severe obstructive sleep apnea and cannot or is unwilling to refrain from continuous positive airway pressure for up to two weeks after the procedure based on expected healing needs and mask types.Up to 2 weeks without CPAP
    3. Evidence describes adults with severe to extreme NOSE scores of 55 or higher.
    Conservative medical management
    Minimum trial durationAt least 4 weeks of conservative medical management is required.
    Required outcomeFailure of benefit must be documented after the conservative treatment trial.
    DocumentationThe failed conservative management must support medical necessity for treatment of symptomatic nasal airway obstruction caused by nasal valve collapse.
    Recent nasal procedure interval
    Look-back intervalNo specified nasal procedure may have been performed within the previous 6 months.
    Procedures includedThe restriction includes functional endoscopic sinus surgery, sinuplasty, septoplasty, inferior turbinate reduction, and rhinoplasty.
    Coverage impactA listed nasal procedure within the previous 6 months is a contraindication to Latera implantation.
    Future concurrent nasal procedure interval
    Post-index intervalNo other concurrent nasal procedure may be required or anticipated within 12 months after the index procedure.
    Concurrent procedures includedExamples include functional endoscopic sinus surgery, rhinoplasty, sinuplasty, septoplasty, and turbinate reduction.
    Procedure relationshipThe restriction applies to procedures outside the index Latera procedure.
    Post-procedure CPAP interruption
    Applicable casesThis requirement applies to qualifying cases of severe obstructive sleep apnea.
    CPAP interruptionThe member must be able and willing to refrain from continuous positive airway pressure for up to 2 weeks after the procedure.
    Basis for durationThe interruption is based on expected healing needs and mask types.
  3. Review planned or anticipated nasal procedures, recent nasal surgery, chronic systemic steroid use, and recreational intranasal drug use.
  4. Document pregnancy or lactation status and the absence of other clinical contraindications.
    5. Denial Risk

    Cosmetic or Other Non-Covered Use

    Latera is not medically necessary for uses outside treatment of symptomatic nasal airway obstruction caused by nasal valve collapse. Uses performed solely for cosmetic reasons, or other non-covered indications, are considered investigational/not clinically proven.

    • Do not submit solely cosmetic nasal contouring or appearance-related treatment as a covered indication.
    • Link the requested implant to documented symptomatic nasal airway obstruction and qualifying nasal valve collapse findings.
    Denial Risk

    Procedure Timing or Anesthesia Contraindications

    Coverage is at risk when the member cannot undergo local anesthesia or when the index procedure overlaps with other nasal procedures. Screen for both planned procedures after implantation and procedures performed recently before implantation.

    • Deny when the member is unable to tolerate or is not a candidate for local anesthesia.
    • Deny when another nasal procedure is required or anticipated within 12 months after the index procedure, including FESS, rhinoplasty, sinuplasty, septoplasty, or turbinate reduction, outside of the index procedure.
    • Deny when FESS, sinuplasty, septoplasty, inferior turbinate reduction, or rhinoplasty was performed within the previous six months.
    Denial Risk

    Clinical Contraindications

    Screen for clinical contraindications before treatment and document the findings. The Latera implant is not appropriate when any listed medication, substance-use, pregnancy, infection, wound, lesion, implant, healing, metabolic, allergy, or treatment-related exclusion is present.

    • Deny for chronic systemic steroid use; recreational intranasal drug use; known or suspected pregnancy; or lactation.
    • Deny for active or concomitant inflammatory or infectious conditions or unhealed wounds in the treatment area, including vestibulitis, vasculitis, or active acne.
    • Deny for cancerous or precancerous nasal lesions, prior radiation to the treatment area, current chemotherapy, or a permanent nasal implant or dilator of any type.
    • Deny for significant healing disorders, including hypertrophic scarring or keloid formation; poorly controlled diabetes mellitus; or known or suspected allergy to Latera implant materials.
    Denial Risk

    Post-Procedure CPAP Restriction

    For a member with severe obstructive sleep apnea, confirm that continuous positive airway pressure can be interrupted for up to two weeks after the procedure as needed for healing. Coverage is at risk when the member cannot or will not refrain from CPAP during that period based on expected healing needs and mask type.

    • Deny when severe obstructive sleep apnea makes post-procedure CPAP interruption impossible or unacceptable to the member.
    • Document the expected healing period, CPAP requirements, and mask considerations.
    The evidence review describes treatment in adults with severe to extreme NOSE scores of 55 or higher.
    Positive Modified Cottle Maneuver
    Examination typeA physical examination maneuver used to assess nasal valve or lateral nasal wall insufficiency.
    Confirmation roleA Positive Modified Cottle Maneuver confirms dynamic bilateral nasal wall insufficiency.
    Coverage relevanceConfirmation by this maneuver is a required criterion for covered Latera implantation.