Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Nasal congestion

Treatment: Current procedural terminology code 30117 [excision or destruction (e.g., laser) of intranasal lesion; internal approach [when used for nasal septal swell body reduction], and code 30117-59 (modifier 59, distinct procedural service)

The insurer denied coverage for current procedural terminology code 30117 [excision or destruction (e.g., laser) of intranasal lesion; internal approach [when used for nasal septal swell body reduction], and code 30117-59 (modifier 59, distinct procedural service)

The denial is overturned

According to the medical records, the patient is a male with a history of nasal obstruction/HA (headache) who has failed medical management with nasal steroid and antihistamine sprays, oral prednisone, nasal saline. 

"Conclusions: The NSB (nasal septal swell body) is a distinct anatomic structure that may contribute to nasal obstruction and may be reduced surgically with unclear long-term results. Although being investigated for over a century, the unique physiological roles of NSB are not yet fully understood. More evidence is needed to elucidate its physiological effects." (Meng, X. et al. 2021).

"Conclusion: The septal swell body is a dynamic structure that varies in width over time in close correlation to the inferior turbinates. Further research is required to quantify its relevance as a surgical area of interest." (Wong, E. H. et at. 2020).

"In this paper, we present the results of coblation nasal septal swell body (NSB) reduction for the treatment of nasal obstruction in patients with abnormally thickened NSB. The study design was a retrospective clinical series conducted at a single tertiary medical center. Eight patients underwent coblation NSB reduction. Pre-operative and post-operative nasal functions were evaluated by acoustic rhinometry and subjective symptom scales. We also analyzed pre-operative CT (computed tomography) scan images and nasal endoscopic findings. The mean maximal NSB width was 16.4  2.2 mm (millimeters) on pre-operative coronal CT scan images. The mean visual analog scale score for nasal obstruction was decreased from preoperative 7.63  0.99 points to 3.88  0.92 points (postoperative 3 months), 4.16  0.78 points (postoperative 6 months), and 4.63  0.69 points (postoperative 1 year). Six out of the eight patients were satisfied with the clinical outcome at 1 year after the procedure. To the best of our knowledge, coblation NSB reduction has not yet been reported in the medical literature. Our results show that it can be an effective treatment modality for nasal valve narrowing in patients with abnormally thickened NSB." (Kim, S. J. et al. 2016). 
The requested service is likely to be more beneficial than any other standard service without increased risk over other surgical intervention.                                        

The carrier's denial of the current procedural terminology code 30117 [excision or destruction (e.g., laser) of intranasal lesion; internal approach [when used for nasal septal swell body reduction], and code 30117-59 (modifier 59, distinct procedural service should be overturned.