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 upheld

This was a gentleman who complained of nasal congestion and sinus congestion. The nasal congestion began months ago and is currently severe. The nasal congestion involved the right and left side of the nose. The sinus congestion began months ago is currently severe. The congestion involved the sinuses bilateral. The symptoms have not been associated with any triggering factors. The patient reports that the condition is uniformly present throughout the day.

There is an undocumented history of prior treatments including antibiotics, antihistamines/T (forehead and nose) congestion combination, antihistamines, intranasal corticosteroids, saline drops, topical decongestant, and oral decongestants.

The physical examination of the nose and nasopharynx revealed that the nasal mucosa was within normal limits, the vestibule was within normal limits, that the inferior turbinate had hypertrophy and that there was a nasal septal deviation. Examination of the nasopharynx with a 0 (degree) telescope noted purulent discharge in the middle meatus.

The CT (computed tomography) found drainage pathway narrowing of the frontal ethmoidal recesses and the sphenoidal ethmoidal recesses and both were patent. Predominantly leftward nasal septal deviation with the septum contacting the left inferior turbinate. 

Impression:

"Minimal to mild and sinusitis with drainage pathway narrowing...Nasal septal deviation with the contact."

The pathology report of the operative procedure stated that:

"Sections reveal inspiratory mucosa with mild chronic inflammation"
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 a CT, who have failed medical therapy, and do not have ostial occlusion. (2,3)

The scientific peer-reviewed literature does support an improvement in health income when proper criteria for surgery are met. There is no report of improvement when these criteria are not fulfilled.

From the information available one cannot determine whether the patient would be a candidate for destruction of this entity of which little is known. (1)

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 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. 

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 upheld.