Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nasal polyps.
Treatment: Procedure code 31296, nasal/sinus endoscopy, surgical, with dilation; frontal sinus ostium (2 units).
The insurer denied coverage for procedure code 31296, nasal/sinus endoscopy, surgical, with dilation; frontal sinus ostium (2 units).
The denial is overturned.

The patient has a history of nasal congestion resultant from nasal polyps. He underwent medical therapy including medrol dose pack, a form of steroid and nose drops. He did not have a significant response to the steroid therapy. A computed tomography (CT) found extensive polyposis occluding in many of his sinuses:

"Both maxillary sinuses are extensively opacified. The bilateral ostiomeatal units are opacified. This appears similar compared to the prior CTA (computed tomography angiogram) study suggesting chronic sinusitis. Moderately extensive mucosal thickening involves the bilateral ethmoid sinuses, similar in overall extent compared to the prior CTA, suggesting chronic sinusitis. Mild to moderate mucosal thickening involves the frontal sinus, most predominantly inferiorly with partial opacification of the frontal sinus outflow tracts. This appears similar in overall extent compared to the previous study. Mild mucosal thickening involves the sphenoid sinus. The sphenoethmoidal recesses are opacified bilaterally, and possibly contiguous with the bilateral nasal soft tissue." "Lobulated soft tissue is noted throughout both nasal cavities, suspicious for underlying nasal polyposis. The soft tissue densities are visually inseparable from the inferior and middle nasal turbinates. The inferior nasal turbinates appear enlarged and extend posteriorly through the choana into the anterior aspect of the nasopharyngeal airway. Chronic maxillary and ethmoid sinusitis are noted as described. Underlying polyposis can't be entirely excluded. Consider follow-up sinus MRI (magnetic resonance imaging) with and without contrast which may help distinguish between obstructed secretions and polyposis."

His physical confirmed the presence of the nasal polyps. 

In summary the patient had massive polyposis obstructing his nasal airway and paranasal sinuses which was refractory to steroid therapy. The peer reviewed literature recommends surgical removal of the polyps when medical therapy failed1-3. 

"Endoscopic sinus surgery should be considered for complications, anatomical variations causing local obstruction, allergic fungal disease or patients who remain very symptomatic despite medical treatment.3"

The health care plan did not act reasonably nor with sound medical judgment and not in the best interest of the patient. The patient had massive polyposis obstructing his nasal airway and paranasal sinuses which was refractory to steroid therapy. The peer reviewed literature recommends surgical removal of the polyps when medical therapy failed. 1-3

The procedure code 31296, nasal/sinus endoscopy, surgical, with dilation; frontal sinus ostium (2 units) is considered medically necessary for this patient as the patient was afflicted with massive nasal and sinus polyps that were refractory of medical therapy. The surgical procedures were appropriate for the care of this patient.1-3 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for procedure code 31296, nasal/sinus endoscopy, surgical, with dilation; frontal sinus ostium (2 units) is overturned. Medical Necessity is substantiated.