Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nasal Congestion.

Treatment: Nose surgery (30117-excision/destruction, intranasal lesion, intranasal approach).

The insurer denied coverage for nose surgery (30117-excision/destruction, intranasal lesion, intranasal approach).

The denial is overturned.

The patient is seeking coverage for nose surgery (30117-excision/destruction, intranasal lesion, intranasal approach).

The patient presented for an evaluation related to nasal congestion.  The patient complained of facial pain, facial pressure, nasal obstruction, and post-purulent drainage.  The patient reported that the symptoms had been ongoing for many years.  Historically, there were no alleviating factors.  The patient had not been on antibiotics or steroids over the past year.  There was no prior sinonasal surgery.  There was a history of asthma which was managed with albuterol.  A computed tomography (CT) scan of the patient was reviewed and showed septal deviation.  There was no evidence of infection.  An updated CT scan showed inflammatory changes in the bilateral anteriorly draining sinuses in association with mucosal disease and variation in ethmoid pneumatization that compromised the drainage pathway.  There was complex nasal septal deviation with osseous spurring.  There was turbinate hypertrophy.  The patient reported fever and being prescribed azithromycin for 5 days without improvement.  The patient complained of mucoid drainage, obstruction, and congestion.  The nasal saline regimen and nasal sprays were ineffective.  The patient's Sino-Nasal Outcome Test-22 (SNOT 22) score was 66.  

Currently, the patient returned to the office for evaluation with complaints of congestion.  The patient had ongoing mucus.  The patient continued with a nasal saline regimen and nasal sprays.  The patient was utilizing budesonide as directed.  The patient reported snoring.  The medication list included azelastine, fluticasone propionate, Medrol Dosepak, Allegra, Pulmicort, ipratropium bromide, and Claritin.  Rigid nasal endoscopy was completed which showed erythema and edema.  There was crusting.  There was hypertrophy of the inferior turbinates.  There was edema of the mucosa and meatus of the middle turbinates.  The patient was assessed with nasal obstruction.  The patient complained of incessant nasal drip.  The drainage continued to be thin and watery despite the medical treatment.  The patient had trialed irrigations, steroid sprays, and antihistamine sprays with minimal benefit.  The patient had slightly hypertrophied inferior turbinates.  There was also nasal drainage collecting in the nasopharynx which appeared to be pooling and contributing to the symptoms.  Given the chronicity of symptoms, there was a plan to proceed with RhinAer and inferior turbinate reduction.  The patient was noted to have a narrowing of the nasal vault and deviation.  The patient would be referred to functional nasal surgery to help address these concerns.

The patient had failed maximal medical therapy for control of rhinitis.  The imaging did not show any additional factors that would cause the patient's symptoms. Therefore, the patient underwent 30117 destructions of intranasal lesions to assist in the control of rhinitis.  It is helpful in many patients with minimal adverse events.  The Desai et al. (2023) article quoted by the reviewer as well as additional well-produced articles by Del Signore et al. (2022) and Ow et al. (2021) also point to improvement with this procedure.  Therefore, the patient's procedure is clinically indicated, medically necessary, and should be approved.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for nose surgery (30117- Excision/Destruction, Intranasal lesion; Int approach) is substantiated.