Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Rhinosinusitis.

Treatment: 31256-50 (nasal/sinus endoscopy, surgical with maxillary antrostomy - bilateral procedure) , 31254-50 (nasal/sinus endoscopy, surgical with ethmoidectomy partial[anterior] - bilateral procedure), and 31237-79-50 (nasal/sinus endoscopy, surgical with biopsy polypectomy or debridement (separate procedure) - unrelated procedure by same physician during the postoperative period - bilateral procedure), endoscopic sinus surgery (ESS).

The insurer denied coverage for 31256-50, 31254-50, and 31237-79-50, endoscopic sinus surgery (ESS).

The denial is overturned.

This patient has a diagnosis of chronic rhinosinusitis with nasal polyps (CRS w/ NP) with nasal obstruction/anomia, despite three-week courses of antibiotics, six times throughout recent years, nasal steroid spray use for four months, and sinus rinse. Computed tomography (CT) sinus showed narrowing of ostiomeatal unit (OMU) bilaterally, mucosal thickening bilaterally, ethmoids, and polyps in the right maxillary sinus.

Codes 31256-50, 31254-50, and 31237-79-50, endoscopic sinus surgery (ESS) is considered more beneficial for this patient's diagnosis. The scientific evidence in peer-reviewed literature support a result of improvement in health outcome.

Per Trombita V., Zolog, A., Toader, M., & Albu, S., "Stenosis of the middle meatus antrostomy (MMA) represents a major cause of recurrent disease following endoscopic sinus surgery (ESS). Various strategies have been developed to prevent the occurrence of MMA stenosis. The performance of a large MMA permitted the achievement of the three-dimensional perspective, allowing one to simultaneously foresee the orbital floor, medial orbital wall, and posterior maxillary wall. The lamina papyracea was skeletonized early during ethmoidectomy to prevent orbital penetration. The removal of all bony septations allowed complete exposure of the lamina. ESS [endoscopic sinus surgery] is considered the treatment of choice in several disorders that compromise maxillary ventilation."

Endoscopic sinus surgery is performed through the nasal openings and is recommended only after it has been determined that medical management has been, or will be, unsuccessful. The applicability of an indicator for a procedure must be determined by the responsible physician in light of all the circumstances presented by the individual patient."     

This patient is a good candidate for codes 31256-50, 31254-50, and 31237-79-50, endoscopic sinus surgery (ESS).

This is the appropriate next step due to the patient failing maximum medical management.    The adverse risks are not increased over standard treatment/services. The patient has already failed medical management; therefore, surgical intervention is the appropriate next step to address the patient's CRS (chronic rhinosinusitis) with NP (nasal polyps) that is confirmed by CT sinus findings that support mucosal thickening and OMU narrowing bilaterally, and that has persisted, despite maximal medical management    

Codes 31256-50, 31254-50 and 31237-50 would be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of codes 31256-50, 31254-50, and 31237-79-50, endoscopic sinus surgery (ESS) should be overturned.