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Medical Policy Rhinomanometry and Acoustic/Optical Rhinometry Table of Contents
• Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 586 BCBSA Reference Number: 2.01.08A (For Plan internal use only) NCD/LCD: N/A Related Policies
None Policy
Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Rhinomanometry and acoustic/optical rhinometry are INVESTIGATIONAL.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

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CPT Codes CPT codes: Code Description 92512 Nasal function studies (eg, rhinomanometry)

Description Rhinomanometry, acoustic rhinometry and optical rhinometry are techniques to objectively measure nasal patency. Several clinical applications are proposed including allergy testing, evaluation of obstructive sleep apnea and patient assessment prior to nasal surgery.

Nasal patency is a complex clinical issue that can involve mucosal, structural and psychological factors. The perception of nasal obstruction is subjective and does not always correlate with clinical examination of the nasal cavity, making it difficult to determine which therapy might be most likely to restore satisfactory nasal breathing. Therefore, procedures that objectively measure nasal patency have been sought. Three techniques that could potentially be useful in measuring nasal patency are as follows:

1. Rhinomanometry is a test of nasal function that measures air pressure and the rate of airflow in the nasal airway during respiration. These findings are used to calculate nasal airway resistance. Rhinomanometry is intended to be an objective quantification of nasal airway patency,
2. Acoustic rhinometry is a technique intended for assessment of the geometry of the nasal cavity and nasopharynx and for evaluating nasal obstruction. The technique is based on an analysis of sound waves reflected from the nasal cavities, and

3. Optical rhinometry uses an emitter and a detector placed at opposite sides of the nose and can detect relative changes in nasal congestion by the change in transmitted light. This technique is based on the absorption of red/near-infrared light by hemoglobin and the endonasal swelling-associated increase in local blood volume.

   Examples of rhinomanometers or acoustic rhinometers to measure nasal patency include device/test/procedure names. All rhinomanometers or acoustic rhinometers to measure nasal patency are considered investigational regardless of the commercial name, the manufacturer or FDA approval status.

   Summary Overall, the scientific evidence does not permit conclusions about the effect of rhinomanometry, acoustic rhinometry or optical rhinometry on net health outcome. To date, no studies have been published that evaluate the clinical utility of these tests. That is, none of the studies identified have prospectively compared patient outcomes with and without the use of one or more of these tests for any clinical condition. Therefore, the technologies are considered investigational.

   Policy History Date Action 11/2022 Annual policy review. Policy updated with literature review through October 2022. No references added. Policy statements unchanged. 4/2020 Policy updated with literature review through March 20, 2020, no references added. Policy statements unchanged. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements.
   12/2011 Annual policy review. No changes to policy statements. 3/2011 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 6/2010 Annual policy review. No changes to policy statements. 3/2010 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 3/2009 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy

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statements. 9/2008 Annual policy review. No changes to policy statements. 3/2008 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 3/2007 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 4/2007 Annual policy review. No changes to policy statements. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

1. Schumacher MJ. Nasal congestion and airway obstruction: the validity of available objective and subjective measures. Curr Allergy Asthma Rep 2002; 2(3):245-51.
2. Larivee Y, Leon Z, Salas-Prato M et al. Evaluation of the nasal response to histamine provocation with acoustic rhinometry. J Otolaryngol 2001; 30(6):319-23.
3. Wilson AM, Sims EJ, Orr LC et al. Effects of topical corticosteroid and combined mediator blockade on domiciliary and laboratory measurement of nasal function in seasonal allergic rhinitis. Ann Allergy Asthma Immunol 2001; 87(4):344-9.
4. Ellegard EK, Hellgren M, Karlsson NG. Fluticasone propionate aqueous nasal spray in pregnancy rhinitis. Clin Otolaryngol 2001; 26(5):394-400.
5. Rhee CS, Kim DY, Won TB et al. Changes of nasal function after temperature-controlled radiofrequency tissue volume reduction for the turbinate. Laryngoscope 2001; 111(1):153-8.
6. Suzina AH, Hamzah M, Samsudin AR. Objective assessment of nasal resistance in patients with nasal disease. J Laryngol Otol 2003; 117(8):609-13.
7. Numminen J, Dastidar P, Heinonen T et al. Reliability of acoustic rhinometry. Respir Med 2003; 97(4):421-7.
8. Mamikoglu B, Houser SM, Corey JP. An interpretation method for objective assessment of nasal congestion with acoustic rhinometry. Laryngoscope 2002; 112(5):926-9.
9. Ceroni Compadretti G, Tasca I, Alessandri-Bonetti G et al. Acoustic rhinometric measurements in children undergoing rapid maxillary expansion. Int J Pediatr Otorhinolaryngol 2005; 70(1):27-34.
10. Ciprandi G, Marseglia GL, Klersy C et al. Relationships between allergic inflammation and nasal airflow in children with persistent allergic rhinitis due to mite sensitization. Allergy 2005; 60(7):957-60.
11. Nathan RA, Eccles R, Howarth PH et al. Objective monitoring of nasal patency and nasal physiology in rhinitis. J Allergy Clin Immunol 2005;115(3 pt 2):S442-59.
12. Wüstenberg EG, Zahnert T, Hüttenbrink KB et al. Comparison of optical rhinometry and active anterior rhinomanometry using nasal provocation testing. Arch Otolaryngol Head Neck Surg 2007; 133(4):344-9.
13. Andre RF, Vuyk HD, Ahmed A et al. Correlation between subjective and objective evaluation of the nasal airway. A systematic review of the highest level of evidence. Clin Otolaryngol 2009; 34(6):518-
15. Canakcioglu S, Tahamiler R, Saritzali G et al. Nasal patency by rhinomanometry in patients with sensation of nasal obstruction. Am J Rhinol Allergy 2009; 23(3):300-2.
16. Pirila T, Tikanto J. Acoustic rhinometry and rhinomanometry in the preoperative screening of septal surgery patients. Am J Rhinol Allergy 2009; 23(6): 605-9.