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

According to the medical records, the patient has nasal congestion and nasal obstruction; the operative note indicates excision of nodular swelling nasal septum for diagnoses of nasal swell bodies and nasal obstruction.

In this case, there is no documentation in the available medical record of examination findings of an intranasal lesion requiring treatment using 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 scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome 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). 

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) do not need final approval from regulatory bodies for this diagnosis. 

This patient is not a good candidate 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) based on the submitted medical record.

The adverse risks of 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) are increased over standard treatment/services in light of no documentation of an intranasal lesion in the submitted medical record. 

The requested service 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) is not likely to be more beneficial than any of the standard treatments/procedures for this patient based on the submitted medical record.                                          

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.