Clinical Policy: Repair of Nasal Valve Compromise Form

# Clinical Policy: Repair of Nasal Valve Compromise
Reference Number: OH.CP.MP.210  
Coding Implications  
Date of Last Revision: 10/25  
Revision Log  

See [Important Reminder](#) at the end of this policy for important regulatory and legal information.  

## Policy Statement  
In compliance with Ohio Medicaid, Buckeye Health Plan must ensure coverage of medically necessary procedures. The plan covers all the services in the amount, duration, and scope that is no less than that covered by FFS Ohio Medicaid and in accordance with 42 CFR 438.210, with limitations, exclusions, and clarifications provided in the Ohio Medicaid Managed Care Provider Agreement and the Ohio Administrative Code. Buckeye Health Plan will not impose hard limits or restrictions on coverage of medically necessary services. Prior to making determinations regarding coverage of services and procedures, Buckeye Health Plan will conduct a medical necessity review for all requests to include non-covered services and any request for services over an established benefit(s).  

## Description  
Medical necessity guidelines for repair of nasal valve compromise.  

  

II. It is the policy of health plans affiliated with Centene Corporation that safety and efficacy have not been established for the following procedures for repair of nasal vestibular stenosis:  
   A. Radiofrequency ablation (VivAer®);  
   B. Absorbable implants (Latera®);  
   C. Nasal valve suspension surgery.  

## Background  
Nasal valve compromise (NVC), also known as nasal valve collapse, is a narrowing of the nasal passageway causing difficult, obstructed breathing. Reasons for NVC are often multifactorial and can be caused by structural weakness or collapse of the nasal valve due to injury or trauma, nasal surgery, chronic inflammation, congenital defects or the natural aging process. NVC may also present as a symptom of rhinitis, sinusitis, septal deviation or adenoid hypertrophy.1,2,3,4,5  

Epidemiology information proposes that up to 13% of patients with chronic nasal obstruction have NVC, and it is primarily a unilateral condition in as many as 88% of patients.6  

Symptoms of NVC include difficulty inhaling through the nose, sensation of congestion, stuffiness, fullness or blockage, nasal bleeding, and snoring. Symptoms may become exacerbated at different times of the day, seasonally, with exposure to different environmental stimuli and in the supine position.1  

When diagnosing NVC there are several specific questions and tests a physician may use in addition to a thorough medial history and physical exam of the nose, nasal cavity, and nasopharynx.1,3  

  

  

Surgical intervention is the primary treatment for NVC and typically consists of insertion of cartilage grafts to support the existing cartilage in the lateral nasal wall or alar rim.7,8,9 There is also consensus that, although a separate entity, correction of a deviated septum or hypertrophied turbinate can sometimes correct NVC.7  

### VivAer®  
The Aerin™ VivAer® procedure is a non-invasive, office-based procedure that employs low-dose radiofrequency (RF) energy to modify soft tissues of the nose with the intent of improving airflow for patients with nasal valve collapse (NVC). The Aerin™ System automatically adjusts the power output to maintain target temperature for therapeutic benefit while sparing surrounding tissue, including mucosa. The RF energy allows tissue to be repositioned laterally and creates a coagulation lesion. As the lesion heals, the tissue retracts and stiffens to lessen the degree of obstruction, decrease the airway resistance, and improve the inhaled flow of air through the nose. The device consists of a console and two styluses, one for nasal airway obstruction and one for chronic rhinitis.6,10  

According to the Hayes Evolving Evidence Review, a review of full-text clinical studies suggests minimal support for using the VivAer radiofrequency procedure for remodeling the nasal valve area when collapse of the nasal valve is associated with chronic nasal obstructive symptoms. VivAer is a novel treatment for nasal airway obstruction that allows delivery of energy to multiple intranasal surfaces (as opposed to only the turbinate) during a treatment session. VivAer can also be used following nasal surgeries, which is a common cause of nasal valve dysfunction. Four clinical studies (one fair quality, two poor quality, one very poor quality) suggest that nasal airway remodeling with VivAer is safe and may result in clinically and statistically significant improvements in patient-reported nasal symptoms due to nasal airway obstruction up to four years posttreatment. It is unclear whether VivAer significantly improves objective measures of nasal patency and airflow, and no studies compared VivAer to active treatment.  

Although there are several ongoing clinical studies of VivAer, most are single-arm and the one comparative study uses a sham control. Additional well-designed comparative studies are needed to determine the effectiveness, safety, and durability of effect of VivAer and how VivAer compares to other active treatments for nasal airway obstruction associated with nasal valve dysfunction. A review of full-text systematic reviews suggests no support for using VivAer for the management of nasal obstruction related to NVC, as there were no systematic reviews identified. Additionally, a full-text review of clinical practice guidelines and position statements suggests no support for using VivAer for the management of nasal obstruction related to NVC due to no guidelines being identified.6  

### Latera®  
Latera® is an absorbable nasal implant used to support the upper and lower cartilage inside the lateral wall of the nose. It is placed under general anesthesia with a 16-gauge cannula via an endonasal access point. Over the course of approximately 12 months following placement, the implant is enveloped by fibrous tissue that helps to maintain stability and positioning. By about 18 months, the implant will have been absorbed and replaced with fibrous collagen matrix that provides continued support. The system consists of the Latera Absorbable Nasal Implant and delivery device as well as an implant positioning guide intended to serve as an external visual planning aid prior to implant placement. The implant is composed of a PLLA-PDLA copolymer.11,12  

Per Hayes’ Evolving Evidence Review, clinical evidence suggests absorbable nasal implants are technically feasible to implant and are associated with reductions in nasal airway obstruction and pain. However, evidence is of generally very poor quality, and there is a paucity of studies with control groups to inform whether absorbable nasal implants have clinical performance that is better, worse, or similar to competing technologies, such as non-absorbable nasal implants. A review of clinical studies suggests minimal support for using absorbable nasal implants for NVC due to poor quality studies that had limited follow up or provided adjunctive treatment with the absorbable nasal implant.11  

## Coding Implications  
Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.  

## CLINICAL POLICY  
Repair of Nasal Valve Compromise  

### CPT Codes That Support Coverage Criteria  
| CPT® Codes | Description |  
|------------|-------------|  
| 30465 | Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction) |  

### CPT Codes Requiring Case by Case Review for Consideration of Coverage Criteria  
| CPT® Codes | Description |  
|------------|-------------|  
| 30468 | Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s) |  
| 30469 | Repair of nasal valve collapse with low energy, temperature-controlled (i.e., radiofrequency) subcutaneous/submucosal remodeling |  

### Reviews, Revisions, and Approvals  
| Revision Date | Approval Date |  
|---------------|---------------|  
| Policy created and approved. | 04/21 | 05/21 |  
| Centene Policy CP.MP. updated with OH Addendum. | 12/23 | 12/23 |  
| Policy moved to Ohio Specific template and Addendum language integrated into policy template as Policy Statement and Procedure. Annual Review completed. No material changes in review criteria. | 07/23 | 07/23 |  
| Annual review completed. References reviewed and updated. | 07/24 | 07/24 |  
| Annual review. Under I.C. added (e.g., sinusitis,...) and removed “including all of the following...”. Removed I.C.1.-I.C.4. Sinusitis... Under I.D. added (e.g., nasal cones, ...) and removed D.1.-D.4. “Eight week trial...). References reviewed and updated. Reviewed by external specialist. | 10/25 | 10/25 |  

.  
5. Ishii LE, Tollefson TT, Basura GJ, et al. Clinical practice guideline: improving nasal form and function after rhinoplasty executive summary. Otolaryngol Head Neck Surg. 2017;156(2):205 to 219. doi:10.1177/0194599816683156  
6. Mohan S, Fuller JC, Ford SF, Lindsay RW. Diagnostic and therapeutic management of nasal airway obstruction: advances in diagnosis and treatment. JAMA Facial Plast Surg. 2018;20(5):409 to 418. doi:10.1001/jamafacial.2018.0279  
7. Lee DS, Glasgold AI. Correction of nasal valve stenosis with lateral suture suspension. Arch Facial Plast Surg. 2001;3(4):237 to 240. doi:10.1001/archfaci.3.4.237  
8. Tasca I, Ceroni Compadretti G, Sorace F. Nasal valve surgery. Acta Otorhinolaryngol Ital. 2013;33(3):196 to 201.  
9. Evolving Evidence Review: VivAer (Aerin Medical Inc.) for nasal airway remodeling to treat nasal obstruction. Hayes. www.hayesinc.com. Updated January 26, 2024. Accessed March 17 2025  
10. Rhee JS, Weaver EM, Park SS, et al. Clinical consensus statement: diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg. 2010;143(1):48 to 59. doi:10.1016/j.otohns.2010.04.019  
11. Local coverage determination. Cosmetic and reconstructive surgery (L35090). Centers for Medicare and Medicaid Services Web site. http://www.cms.hhs.gov/mcd/search.asp. Published October 01, 2015 (revised July 11, 2021). Accessed March 17 2025  
12. Local coverage determination. Cosmetic and reconstructive surgery (L33428). Centers for Medicare and Medicaid Services Web site. http://www.cms.hhs.gov/mcd/search.asp. Published October 01, 2015 (revised July 29, 2021). Accessed March 17 2025  
13. Aerin Medical website. https://aerinmedical.com/. Accessed March 17 2025  
14. Evolving Evidence Review: Absorbable nasal implants (Latera, Stryker) for the treatment of nasal valve collapse. Hayes. www.hayesinc.com. Published March 10, 2022.  
15. Stryker website. https://latera.com/. Accessed March 17 2025  
16. Schmale IL, Yao WC, Luong AU, Citardi MJ. The role of CT and endoscopy in the evaluation of patients referred for intranasal Cryoablation. Am J Otolaryngol. 2021;42(4):102971. doi:10.1016/j.amjoto.2021.102971  
17. Lieberman PL. Chronic nonallergic rhinitis. UpToDate. www.uptodate.com. Updated October 22, 2023. Accessed March 17 2025  
18. Schmale IL, Yao WC, Luong AU, Citardi MJ. The role of CT and endoscopy in the evaluation of patients referred for intranasal Cryoablation. Am J Otolaryngol. 2021;42(4):102971. doi:10.1016/j.amjoto.2021.102971  

## Important Reminder  
This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. Buckeye Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.  

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.) as well as to state and federal requirements and applicable Buckeye Health Plan-level administrative policies and procedures.  

This clinical policy is effective as of the date determined by Buckeye Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.  

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.  

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom Buckeye Health Plan has no control or right of control. Providers are not agents or employees of Buckeye Health Plan.  

This clinical policy is the property of Buckeye Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such term exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.  

**Note:** For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.  

## CLINICAL POLICY  
POLICY TITLE Repair of Nasal Valve Compromise  

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