Diagnosis: Hypertrophied Turbinates.

Treatment: VivAer nasal airway reconstruction procedure.

The insurer denied coverage for VivAer nasal airway reconstruction procedure.

The denial is overturned.

This case involves a male who has previously been diagnosed with obstructive sleep apnea and chronic rhinitis. The documentation indicated he was seen for a follow-up and it was noted he would benefit from myofunctional exercises. It is noted he has 3-4 episodes of ethmoidal sinusitis typically treated with antibiotics. Per provided documentation he has had a trial of positive airway pressure (Pap) therapy however he was not able to maintain. He has also undergone uvulopalatopharyngoplasty (UPPP) surgery and utilized an oral appliance. He did have moderate hypertrophy bilaterally on prior examination. He did have a diagnosis of obstruction of nasal valve and has utilize nasal sprays and Latera implants. The documentation indicated he underwent the requested procedure due to ongoing symptoms.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.

The VivAer nasal airway reconstruction procedure has final approval from the appropriate regulatory bodies for this diagnosis.

He was a good candidate based on pathology, symptoms and a failure of multiple medications and treatment.

VivAer nasal airway reconstruction procedure is the best available treatment for this patient at this time. The adverse risks do not increase over standard treatment/services.

According to peer-reviewed literature, temperature-controlled radiofrequency treatment of nasal valve collapse is safe and effective in reducing symptoms of nasal airway obstruction (NAO). The literature does indicate nasal valve collapse is 1 of several causes of nasal obstruction. The safety and efficacy of the requested procedure to treat the above has been established. The documentation indicated this patient was diagnosed with rhinitis in addition to nasal valve collapse and obstructive sleep apnea. The documentation indicated he has had a trial of multiple treatments to include surgical intervention, the use of an oral appliance, medication management, and Pap therapy. He did have evidence of moderate hypertrophy bilaterally in addition to obstruction of nasal valve. He exhausted other conservative treatment and therefore, given the requested procedure is noted to be safe and effective, the prior denial is overturned.

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of VivAer nasal airway reconstruction procedure should be overturned.