Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Sinusitis. 
Treatment: Sinus Surgery. 

The insurer denied the Sinus surgery. 
The determination is oveturned in part. 

The patient has a history of recurrent sinusitis. The patient was experiencing in excess of 5-6 episodes of sinus infections per year. Treatment prior to surgery included 5-6 courses of oral antibiotics, nasal steroids, oral antihistamines, and decongestants. A pre-operative computed tomography (CT) scan of the sinuses noted complete opacification of the majority of the paranasal sinuses (Lund-Mackay score of 32 and obstruction of bilateral osteomeatal complexes). Based on the pre-operative history and radiographic history, the patient was recommended to undergo endoscopic sinus surgery with balloon dilation of the maxillary, sphenoid, and frontal sinuses. 
Examination noted middle meatus narrowing, inferior turbinate hypertrophy and nasal septum deviation to the left. A zero-degree endoscopy noted purulent discharge in both middle meati with nasal polyps. 
For the surgery, the following current procedural terminology (CPT) codes were submitted: 
31298-50 Nasal/sinus endoscopy with balloon dilation frontal/sphenoid sinuses, 
30140-50 Submucousal reduction of inferior turbinates, 
31254-50 Nasal/sinus endoscopy with ethmoidectomy, 
31295-50 Nasal/sinus endoscopy with balloon dilation maxillary sinuses, 
30117 Destruction of intra-nasal lesion (ie ablation of nasal swell bodies), 
the patient underwent the sinus surgery, turbinate reduction, and radiofrequency ablation of the nasal swell bodies (in-office setting). 
CPT codes 31298, 31295, 30117 were denied by the health plan. At issue is whether the proposed health service or treatment sinus surgery is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

The proposed sinus surgery is more likely to be beneficial than the standard medical treatment for chronic sinus disease. Current evidence in the literature supports the use of balloon dilation as an alternative treatment for treatment for recurrent/chronic sinusitis.
However, there is limited evidence in the scientific literature that swell body treatment is more beneficial to patients. In addition, there is a failure to support its use (double blinded randomized control studies) in patients undergoing endoscopic sinus surgery. 
 The patient does have a significant history of recurrent sinusitis. This was confirmed with physical exam and computed tomography (CT) scan. Prior treatment with oral antibiotics failed along with other conservative measurements. The proposed surgery to address the paranasal sinuses with balloon dilation (frontal, sphenoid, and maxillary sinuses) was indicated. Bozdemir et al 2011 supported hybrid procedure (polypectomy and balloon dilation) as a reasonable method to address sinus disease. Furthermore, balloon dilation does have support in both the literature and otolaryngology community as an effective method to treat sinus disease (Piccirillo et al 2018). 

The health plan's determination is overturned in part. Of the current procedural terminology (CPT) codes under review, the following are indicated: 
31298-50 Nasal/sinus endoscopy with balloon dilation frontal/sphenoid sinuses, 
31295-50 Nasal/sinus endoscopy with balloon dilation maxillary sinuses
CPT code 30117 is not indicated.