Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Nasal/sinus endoscopy, surgical, with dilation (eg, balloon 
dilation); maxillary sinus ostium, transnasal or via canine fossa (31295) and Nasal/sinus endoscopy, surgical, 
with dilation (eg, balloon dilation); frontal sinus ostium (31296). 
 
You asked the Plan to pre-approve Nasal/sinus endoscopy, surgical, with dilation; maxillary and frontal sinus 
ostium. You say that your records do not show confirmation of chronic rhinosinusitis on a computed 
tomography (CT) scan. The Plan denied your request. The Plan says that your doctor is recommending this 
procedure to end a cycle of infections. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Nasal/sinus endoscopy, surgical, with 
dilation, maxillary and frontal sinus ostium. Our reviewer says that the requested items/services are considered 
medically reasonable and necessary in this case. Our physician reviewer found that based on the medical 
records provided there is documentation that the endoscopic nasal/sinus surgery at issue in your case meets 
Medicare criteria for medically reasonable and necessary and safe and effective. The most recent provided 
records showed mucoid drainage and edema in the nasal cavity and a computed tomography scan from June 21, 
2023, showed no significant sinus inflammatory changes. You have documented symptoms of recurrent facial 
pain and recurrent sinus infections requiring antibiotics (six infections between October 2022, and June 2023). 
Although provided records do not show evidence of mucosal inflammation on a CT scan, there is evidence of 
mucoid drainage and edema on direct visualization of the nasal cavity by the otolaryngologist along with the 
history of chronic rhinosinusitis despite multiple courses of antibiotics, Singulair, Flonase and 
azelastine. Records support this surgery meets criteria for medically reasonable and necessary and safe and 
effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nasal/sinus endoscopy, surgical, with dilation; maxillary and frontal sinus 
ostium have been met. Therefore, we decided that the Plan has to pre-approve Nasal/sinus endoscopy, surgical, 
with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa (31295) and 
Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium (31296).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.