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Medical Policy

Policy Num:       07.001.095
Policy Name:     COBLATION ASSISTED TONSILECTOMY 
Policy ID:          [07.001.095][Ac L M- P- ][0.00.00]

Last Review:       November 10, 2021
Next Review:      N/A
Issue:                   November, 2021

Archived Policy

Related Policies: 

7.01.56 Laser-Assisted Tonsillectomy

COBLATION ASSISTED TONSILECTOMY

Summary

Standard electro-surgical instruments and lasers use thermal energy. Other methods to break down tissues have been developed to address the problem of high temperature and damage to surrounding tissues. Coblation is a non-thermal method where the tissue volume is removed through a molecular dissociation similar to the laser exempt. Coblation uses the fluid between the instrument (electrode) and the tissue as a conductor. When electric current is applied to this fluid it becomes charged particles and is called the plasma layer. These charged particles are accelerated by the plasma creating enough energy to break the molecular bonds within the cell. This produces the disintegration of the cells molecule by molecule. In this way, the volume of tissue is reduced.

Assisted surgery by coblation uses a continuous mode of operation rather than the pulse mode used by lasers. The purpose of using a continuous mode is to allow coagulation in small vessels, hemostasis in larger vessels and decrease in collagen. Coaling uses relatively low temperatures compared to laser, thus reducing damage to adjacent tissues.

Objective

The objective of this evidence based review is to evaluate the possible benefit of coblation assisted tonsillectomy in overall wellbeing and post op morbidity.

Policy Statements

Tonsillectomy by coblation is not considered for additional payment for the treatment of any of the following conditions when considering conventional surgery modality.

• Peritonsillar abscesses
• Recurrent middle ear infections
• Recurrent or chronic infections in the tonsils
• Hypertrophy of the tonsils associated with respiratory symptoms or obstruction of the upper respiratory tract.
 

Policy Guidelines

No specific codes.

Benefit Application

BlueCard/National Account Issues

Coblation is considered a modality of surgery and does not have additional compensation versus conventional surgery modality. 

Background

Standard electro-surgical tools and lasers remove tissue by thermal energy.  Other methods of tissue decomposition have evolved to try to address the problems associated with high heat and damage to the surrounding tissue.

Coblation is a method of non-thermal volumetric tissue removal through molecular dissociation, similar to that of excimer lasers.  When electrical current is applied to this fluid, it turns into a charged layer of particles, called a plasma layer.  Charged particles accelerate through the plasma and gain sufficient energy to break the molecular bonds within cells.  This causes the cells to disintegrate molecule by molecule, so that tissue is volumetrically removed.

Coblation-assisted surgery uses a continuous mode of operation rather than the pulsed mode required for lasers.  The purpose of a continuous mode of operation is to allow for coagulation of smaller blood vessels, and when used in sub-ablation mode, the intent is to produce hemostasis in larger vessels as well as shrinkage of collagen.  Coblation uses a relatively low-temperature plasma, compared with lasers of high-power density beam of photons with their subsequent heat production.  Because Coblation uses a low-temperature, the intent is to decrease the risk for thermal damage to surrounding tissues.  ArthroCare believes Coblation will provide a more precise operative result, reduce surgical time, speed recovery and reduce post-operative pain.  However, these claims are not supported by well controlled randomized studies.

Regulatory Status

N/A

Rationale

A Cochrane evidence review (Burton and Doree, 2007) concluded that, "In terms of postoperative pain and speed and safety of recovery, there is inadequate evidence to determine whether coblation tonsillectomy is better or worse than other methods of tonsillectomy.  Evidence from a large prospective audit suggests that it has been associated with a higher level of morbidity, in terms of postoperative bleeding.  Large, well-designed randomised controlled trials supplemented by data from large prospective audits are needed to produce information on effectiveness and morbidity respectively."

2007-2008 Update A search of the MEDLINE database for the period of November 2006 through December 2007 identified several studies on laser-assisted tonsillectomy. One study was a randomized within-subject double-blind comparison of tonsillectomy performed with laser, blunt dissection, electrocautery, or radiofrequency coblation. (4) For each of the 60 adult patients, tonsillectomy was performed with coblation on one randomly chosen side; for the other tonsil one of the other 3 “standard” techniques was used (20 patients per comparison group). Pain ratings were higher for laser and electrocautery than for blunt dissection and coblation. Both operative time and blood loss were higher for laser (20 minutes and 20 mL, respectively) than coblation (10 minutes and 2.5 mL). Laser and electrocautery resulted in more histopathological thermal tissue injury than coblation. Healing, determined by a blinded evaluator, was slower for electrocautery, but similar for blunt dissection, laser, and coblation. No evidence was found to suggest that use of a laser improves health outcomes in comparison with other methods.

Population Reference No. 1 Policy Statement

For individuals with peritonsillar abscesses. Interventions of interest are coblation assisted tonsillectomy. Comparators of interests are standard electro-surgical instruments and lasers. The evidence is insufficient to determine the effects of the technology on health outcomes.

Population Reference No. 2 Policy Statement

For individuals with recurrent middle ear infections. Interventions of interest are coblation assisted tonsillectomy. Comparators of interests are standard electro-surgical instruments and lasers. The evidence is insufficient to determine the effects of the technology on health outcomes.

Population Reference No. 3 Policy Statement

For individuals with recurrent or chronic infections in the tonsils. Interventions of interest are coblation assisted tonsillectomy. Comparators of interests are standard electro-surgical instruments and lasers. The evidence is insufficient to determine the effects of the technology on health outcomes.

Population Reference No. 4 Policy Statement

For individuals with hypertrophy of the tonsils associated with respiratory symptoms or obstruction of the upper respiratory tract. Interventions of interest are coblation assisted tonsillectomy. Comparators of interests are standard electro-surgical instruments and lasers. The evidence is insufficient to determine the effects of the technology on health outcomes.

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1. Auf I, Osborne JE, Sparkes C et al. Is the KTP laser effective in tonsillectomy? Clin Otolaryngol 1997; 22(2):145-6.
2. Nelson LM. Radiofrequency treatment for obstructive tonsillary hypertrophy. Arch Otolaryngol Head Neck Surg 2000; 126(6):736-40.
3. Scott A. Hot techniques for tonsillectomy. Issues Emerg Health Technol 2006; (93):1-6. Accessible at http://www.cadth.ca/media/pdf/E0003_tonsillectomy_cetap_e.pdf .
4. Magdy EA, Elwany S, El-Daly AS et al. Coblation tonsillectomy: a prospective, double-blind, randomised, clinical and histopathological comparison with dissection-ligation, monopolar electrocautery and laser tonsillectomies. J Laryngol Otol 2007
5. National Institute for Health and Clinical Science. Tonsillectomy using laser. Accessible at http://www.nice.org.uk/nicemedia/pdf/ip/IPG186guidance.pdf . Issued July 2006; last viewed February 2009.
6. Reichel O, Mayr D, Winterhoff J et al. Tonsillotomy or tonsillectomy?--a prospective study comparing histological and immunological findings in recurrent tonsillitis and tonsillar hyperplasia. Eur Arch Otorhinolaryngol 2007; 264(3):277-84.
7. Hegazy HM, Albirmawy OA, Kaka AH et al. Pilot comparison between potassium titanyl phosphate laser and bipolar radiofrequency in paediatric tonsillectomy. J Laryngol Otol 2008; 122(4):369-73.

Codes

Applicable Modifiers

Some modifiers.

Policy History