Prior authorization note — Indiana asterisked codes

Codes labeled with an asterisk (*) are not managed for medical necessity review for the state of Indiana at the time this policy became effective; refer to the most up to date prior authorization list for Indiana.

Prior authorization likely required for implants/procedures

Prior authorization is likely required for implantable devices and related procedures; provide randomized trial or cohort evidence supporting use in patients with severe-to-extreme NOSE scores and documentation that less invasive measures were unsuccessful or unsuitable.

Confirm failure of medical therapy and trial eligibility

Prior authorization requests should confirm documented failure of medical therapy and that patients meet trial-like eligibility criteria (for example, chronic rhinitis ≥6 months and trial-specific rTNSS/NOSE thresholds) before approval is considered.

Prior authorization eligibility checklist

Use an eligibility checklist at prior authorization to verify symptom chronicity (≥6 months), inadequate response to medical therapy (e.g., intranasal steroids), baseline validated symptom scores meeting trial thresholds (rTNSS or NOSE), and a rationale for device/procedure selection.

• Chronicity ≥6 months
• Documented inadequate response to medical therapy (e.g., intranasal steroids)
• Baseline validated symptom scores meeting trial thresholds (rTNSS or NOSE)
• Rationale for device/procedure selection

Prior authorization: required clinical details

Prior authorization should request specific clinical information including baseline NOSE score, prior interventions (medical and procedural), and the planned device or procedure (e.g., VivAer) with documentation that nasal valve collapse is a primary contributor to symptoms and a plan for follow-up.

• Baseline NOSE score
• Prior interventions and durations
• Planned device/procedure and rationale
• Plan for follow-up assessments

Check benefit requirements and provide records

Before submitting for coverage under this policy, check federal, state, or contractual benefit requirements; medical records may be required for review to assess whether the member meets clinical criteria for coverage.

Conservative therapy requirement

Document that adequate maximal conservative medical therapy was tried and failed — persistent nasal obstruction must follow maximal therapy (for example, nasal steroids, antihistamines, decongestants) prior to considering nasal valve procedures or device placement.

• Records showing trials of topical nasal steroids, antihistamines, and decongestants
• Statement that obstruction persisted despite maximal therapy

Step therapy considerations — AAO-HNS guidance

AAO-HNS guidance indicates that the final decision on use of biomaterials (implants, stents) should be individualized by the treating physician and not necessarily delayed by stepwise requirements when evidence shows early benefit.

Step therapy: document medical management before procedure

Clinical series and trials typically included patients who had failed topical nasal medications; prior medical management (including at least 4 weeks of intranasal steroids where applicable) should be documented before procedural intervention.

• Document inadequate symptom relief over at least 4 weeks of nasal medications when applicable

Step therapy expectation for PNN/TCRF — refractory cases

PNN ablation and TCRF approaches are considered for medically refractory cases after failed conservative therapy; prior therapies and their failures should be documented in the record to support use.

Step therapy (informational) — no explicit algorithm

This policy does not provide an explicit step therapy algorithm; external evidence reviews recommend comparative studies versus other nasal airway obstruction treatments before broad substitution of procedures.

Medical record documentation requirement

The patient's medical record must contain documentation supporting medical necessity, including relevant history, physical examination, and results of pertinent diagnostic tests or procedures; documentation must be legible and available upon request.

Required clinical documentation — examples

Include specific clinical documentation such as baseline NOSE (or other disease-specific QOL) scores, prior conservative treatments and durations, specific diagnosis of nasal valve collapse or lateral wall insufficiency, and whether concurrent procedures are planned or performed.

• Baseline NOSE or rTNSS scores
• Prior conservative treatments and durations
• Diagnosis confirming nasal valve collapse or lateral wall insufficiency
• Details of concurrent procedures (e.g., septoplasty, turbinate reduction)

Requirement: prior medical management documented

Clinical evaluations must document failure of medical management — for chronic rhinitis this includes inadequate symptom relief over at least 4 weeks of nasal medications (steroids, antihistamines, and/or anticholinergics) prior to considering PNN cryoablation, consistent with study populations.

Required clinical documentation — symptom scores and therapy details

Clinical records should document symptom severity (for example, rTNSS or NOSE scores), prior medical therapy failure (including duration and specific agents), and eligibility criteria similar to trial inclusion (e.g., baseline rTNSS ≥4 or ≥6 depending on study) to support medical necessity.

• Symptom severity scores (rTNSS, NOSE)
• Duration and agents of prior therapies
• Trial-like eligibility thresholds (documented)

Required clinical documentation — NOSE and valve attribution

Clinical documentation should include baseline NOSE Scale score and an indication that nasal valve collapse is the primary or a significant contributor to nasal airway obstruction; for longitudinal analyses, note whether additional nasal procedures were performed and exclude those from device outcome analyses when appropriate.

• Baseline NOSE Scale score
• Statement that nasal valve collapse is primary contributor
• Record of additional nasal procedures (if any)

Medical records must fully support medical necessity

The patient's medical record must contain legible documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; documentation must be made available upon request.

Coding review and cosmetic determination

All nasal surgical claims may be subject to coding review; listed codes may be classified as cosmetic and require review to determine whether the service is cosmetic or reconstructive for coverage purposes.

Evidence limitations may trigger denial

Evidence limitations—such as lack of long-term follow-up, small sample sizes, subjective outcome measures, and risk of bias—may lead to denials or requests for additional justification for absorbable implants and related procedures.

Study design limitations that affect authorization

Some studies lack sustained control groups, did not manage concurrent medication use, or included crossover designs; these limitations may affect determinations of medical necessity in individual cases.

Evidence limitations affecting authorization

Short follow-up, absence of objective measures, or failure to meet study-like inclusion criteria (for example, minimum rTNSS thresholds) may limit evidence for coverage and could result in denial if medical necessity is not demonstrated in the record.

Denial risk due to limited evidence

Evidence limitations—including small studies, short follow-up, and lack of comparative groups—may trigger coverage denials if documentation cannot demonstrate medical necessity and expected benefit.

Documentation-related denial risk

Lack of adequate medical records documentation that fully supports medical necessity may lead to denial or inability to approve requested services.