CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

absorbable_lateral_nasal_implant_policy

Defines coverage determination for insertion of an absorbable lateral nasal implant to treat symptomatic nasal valve collapse for BlueCHiP for Medicare and Commercial products; includes coding guidance and rationale.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

Policyabsorbable_lateral_nasal_implant_policy

Policy CodePolicy N/A

Change TypeClarified final coverage stance

Effective DateJan 1, 2019

Next Review Date

Key ActionVerify member-specific benefits and eligibility; coverage may vary by group/contract and Evidence of Coverage or Subscriber Agreement governs coverage.

SourceLink

POLICY UPDATE CHANGES

Policy states insertion of absorbable lateral nasal implant is not covered (Medicare) / not medically necessary (Commercial) due to insufficient evidence.

1Primary coverage stance (not covered/not medically necessary)

1Not covered HCPCS code listed

2Cited prospective single-cohort studies

Coverage Summary

This policy defines coverage for the insertion of an absorbable lateral nasal implant to treat symptomatic nasal valve collapse for BlueCHiP for Medicare and Commercial products. For BlueCHiP for Medicare, the insertion of an absorbable lateral nasal implant for the treatment of symptomatic nasal valve collapse is not covered because the evidence is insufficient to determine the effects of the technology on health outcomes. For Commercial products, the insertion of an absorbable lateral nasal implant for the treatment of symptomatic nasal valve collapse is considered not medically necessary for the same reason.

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Coverage determination

Policy statements for BlueCHiP for Medicare and Commercial products:

BlueCHiP for Medicare: The insertion of an absorbable lateral nasal implant for the treatment of symptomatic nasal valve collapse is considered not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.
Commercial products: The insertion of an absorbable lateral nasal implant for the treatment of symptomatic nasal valve collapse is considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.
Benefit variability: Benefits may vary between groups/contracts; refer to Evidence of Coverage or Subscriber Agreement for applicable not medically necessary/not covered benefits/coverage.

Provider Actions

Documentation Required

Benefit/coverage verification

Verify member-specific benefits and eligibility; coverage may vary by group/contract and Evidence of Coverage or Subscriber Agreement governs coverage.

Billing Rule

Procedure coding for implant placement

Report physician work for nasal implant placement with unlisted CPT code 30999; some providers may use CPT 30465 but 30999 is most appropriate. The device HCPCS code C9749 is considered not covered/not medically necessary.

30999
30465
C9749 (not covered)

Denial Risk

Service not covered / not medically necessary

Claims for insertion of an absorbable lateral nasal implant for symptomatic nasal valve collapse are subject to denial as not covered (Medicare) or not medically necessary (Commercial) per this policy.

C9749
Claims for C9749 are subject to denial per this policy

Coding

Not covered / Not medically necessary codeHCPCSNot Covered

C9749

Repair of nasal vestibular lateral wall stenosis with implant(s) implant placement

Physician procedure coding guidanceCPT

30999	Unlisted procedure, nose (recommended for physician work for the nasal implant placement)
30465	Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal reconstruction) — cited as sometimes used but unlisted code 30999 is most appropriate

Coding guidance: Physician work for nasal implant placement should be reported with the unlisted CPT code 30999. Some providers may use CPT 30465, but 30999 is most appropriate. The device HCPCS code C9749 is listed as not covered / not medically necessary under this policy.

Background and Evidence Summary

Background: Absorbable lateral nasal implants have been proposed as an alternative to grafting to support the lateral nasal cartilages for internal/external nasal valve collapse. The evidence consists of two nonrandomized, industry-sponsored prospective single-cohort studies.

Limitations of the evidence include heterogeneous study populations with incompletely described types and rates of concurrent nasal procedures and clinical rationale for adjunctive interventions; incomplete procedural detail and missing data elements for important outcomes; generally short follow-up relative to device absorption and tissue remodeling; and device retrievals reported in approximately 10% of patients in the primary cohort. Overall the evidence is insufficient to determine the effects of the technology on health outcomes.

Key evidence facts

Device retrieval rateApproximately 10% reported in primary cohort

Duration of device absorptionDevice absorption ~18 months; tissue remodeling purported complete by 24 months

Study designTwo nonrandomized, prospective single-cohort industry-sponsored studies (no RCTs)

Nasal Obstruction Symptom Evaluation (NOSE) score: A patient-reported outcome measure used to assess nasal obstruction symptom severity, cited as an outcome in study reports.

Revision History

2019-01-01policy_change

Reflects final coverage stance; document published Provider Update January 2019. Policy states insertion of absorbable lateral nasal implant is not covered (Medicare) / not medically necessary (Commercial) due to insufficient evidence. Detail: For BlueCHiP for Medicare the insertion of an absorbable lateral nasal implant for symptomatic nasal valve collapse is considered not covered as the evidence is insufficient to determine the effects on health outcomes; For Commercial products the insertion is considered not medically necessary for the same reason.