Appeal type: Experimental/Investigational
Decision: Overturned in Part

Diagnosis: Bilateral recurrent, acute and chronic maxillary, frontal, sphenoid and ethmoid sinusitis with nasal polyps

Treatment: Codes 30117 - excision or destruction (e.g. [for example], laser), intranasal lesion; internal approach and 31254 - nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior)

The insurer denied coverage for codes 30117 excision or destruction (e.g., laser), intranasal lesion; internal approach and 31254 nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior).

The denial is upheld.

This patient presented with a history of nasal and sinus congestion. The nasal congestion began years ago and is currently severe. The nasal congestion involves the right and left sides of the nose. The sinus congestion began years ago and is currently severe. The congestion involves the sinuses bilaterally. The symptoms have not been associated with any triggering factors. The patient reports that the condition is uniformly present throughout the day.

Prior treatments included antibiotics, antihistamine/decongestant combinations, antihistamines, avoidance of allergens, intranasal corticosteroids, prior nasal surgery, saline nasal drops, topical decongestants, and oral decongestants.

The patient underwent a "bilateral endoscopic nasofrontal duct balloon dilatation, bilateral sphenoidotomies with endoscopic balloon dilation, bilateral maxillary antrostomies with balloon dilation, bilateral anterior ethmoidectomies with nasal polypectomies, bilateral submucous resection of inferior turbinates with excision of nodular swelling and polyps on the nasal septum bilaterally."

The peer-reviewed literature states that balloon dilatation is not appropriate for patients who do not have a documented history of chronic sinusitis, who do not have both sinonasal symptoms and positive findings on CT (computed tomography), who have failed medical therapy, and do not have ostial occlusion [2,3].

The information available does not document the criteria needed for balloon dilatation. 

PubMed for Nasal Swell Body Randomized Controlled Trial found only one article [4]. This showed a subjective difference but not an objective measure in a study of 39 patients. The scientific peer-reviewed literature does support an improvement in health outcome when the proper criteria for surgery are not met. There is no information as to when these criteria were fulfilled.

From the information available, one cannot determine whether the swell body exist in this patient and it cannot be determined whether the patient would be a candidate for destruction of this entity of which little is known. The patient, from the information available did not meet the criteria for surgery and he was not a good candidate for the surgery.

The current procedural requests are not the best available treatment for this patient at this time, as there is no evidence the patient has morbidity associated with a possible nasal septal swell body. The information available did not support the peer reviewed criteria for nasal/sinus endoscopy, surgical with ethmoidectomy; partial anterior.

The adverse risks are increased as there were no indications for surgery.

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient as there were no indications for the surgery.

The denial should be upheld as noted in the peer reviewed literature there were no indications for the surgery [2,3]. The history from the information available does not document the criteria needed for balloon dilatation. 

The carrier's denial of codes 30117 excision or destruction (e.g. [for example], laser), intranasal lesion; internal approach and 31254 nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior) rendered should be upheld.