Appeal type: Experimental/Investigational
Decision: Overturned

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 overturned.

This patient has a history of bilateral recurrent, acute and chronic maxillary, frontal, sphenoid, and ethmoid sinusitis with nasal polyps, deviated nasal septum with hypertrophied inferior turbinates, with nasal obstruction. The patient has severe nasal congestion and sinus congestion. His treatment history includes antibiotics, antihistamine/decongestant combination, antihistamines, avoidance of allergens, intranasal corticosteroids, prior nasal surgery, saline nasal drops, topical decongestants, and oral decongestants. There were no alleviating factors for his condition. The patient underwent a procedure for a bilateral endoscopic nasofrontal duct balloon dilatation, bilateral sphenoidotomies with endoscopic balloon dilatation, bilateral maxillary antrostomies with balloon dilatation, bilateral anterior ethmoidectomies with nasal polypectomies, bilateral submucous resection of the inferior turbinates with excision of nodular swelling and polyps on the nasal septum bilaterally. Current Procedural Terminology (CPT) 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 is under review.

The 30117 excision or destruction (e.g., laser), intranasal lesion; internal approach code is supported in peer-reviewed literature to improve health outcomes involving nasal obstruction. 

"Nasal septal swell body (NSB) is closely related to the internal nasal valve. Imaging studies have found that the size of NSB is associated with nasal diseases, and NSB hypertrophy can cause anatomic obstruction. In recent years, several procedures for NSB have been reported, and preliminary effectiveness has been achieved." (Meng, et al, 2021)

The patient is a good candidate, he has severe nasal congestion and sinus congestion. His treatment history includes antibiotics, antihistamine/decongestant combination, antihistamines, avoidance of allergens, intranasal corticosteroids, prior nasal surgery, saline nasal drops, topical decongestants, and oral decongestants. There were no alleviating factors for his condition.

Codes 30117 excision or destruction (e.g., laser), intranasal lesion; internal approach, and 31254 nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior) rendered is the best available treatment for this patient at this time.

The patient has severe nasal congestion and sinus congestion. His treatment history includes antibiotics, antihistamine/decongestant combination, antihistamines, avoidance of allergens, intranasal corticosteroids, prior nasal surgery, saline nasal drops, topical decongestants, and oral decongestants. There were no alleviating factors for his condition. He has failed medical management, and the procedures will provide relief of the symptoms, as well as help make any further congestion more manageable. Therefore, codes 30117 excision or destruction (e.g., laser), intranasal lesion; internal approach and 31254 nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior) rendered is likely to be more beneficial.

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