Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Rhinitis

Treatment: Current Procedural Terminology (CPT) 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures].

The insurer denied coverage for Current Procedural Terminology 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures].
The denial is upheld

This case involves an adult with chronic rhinitis who underwent intranasal destruction of intranasal lesion via cryotherapy (ClariFix). The visit note stated the patient had nasal congestion and ear fullness. The patient had a past medical history significant for nasal surgery (cosmetic rhinoplasty and septoplasty), use of Flonase for at least one year, and was found to have cerumen impaction along with clear secretions from the nasal cavity. The impression at that time was postnasal drip and nasal congestion along with chronic rhinitis, bilateral cerumen impaction, and sensorineural hearing loss. The patient underwent nasal endoscopy with plans to have the patient undergo a posterior nasal nerve neurolysis bilaterally to address the chronic rhinitis. Surgery was completed with preoperative diagnoses consisting of vasomotor rhinitis and chronic rhinitis with persistent rhinorrhea despite medical therapy.  

The scientific evidence in peer-reviewed literature does not fully support a result of improvement in health outcome. Current Procedural Terminology 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures] performed needs final approval from the appropriate regulatory bodies for this diagnosis.

This patient is not a good candidate for Current Procedural Terminology 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures]. Current Procedural Terminology 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures] is not the best available treatment for this patient at this time.

Current medical literature has noted that posterior nasal nerve (PNN) cryoablation is a novel surgical technique used to address chronic rhinitis.  Case series have shown meaningful clinical improvement in 75-80% (percent) of patients, but variables predicting pain and cryoablation success have not been studied. Records claimed that the patient had refractory rhinorrhea despite the use of Flonase and azelastine for more than a year. However, the procedure conducted has not been confirmed as the standard of treatment for the patient's condition. Ongoing studies are still showing promising results. While it has been found to be safe and effective both in the office in ambulatory settings, scientific evidence and peer-reviewed literature does not fully support a result of improvement in health outcomes.

In summary, the denial of procedure code 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures] and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks have not been found to be substantially increased over standard treatment/services