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 modified.

The patient has a history of bilateral recurrent, acute and chronic maxillary, frontal, sphenoid and ethmoid sinusitis with nasal polyps and 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.

Regarding the anterior ethmoidectomy code (31254), patient had polyps on examination and presence of mucocele on CT (computed tomography) scan. The patient has been treated with antibiotics, antihistamine/decongestant combination, antihistamines, avoidance of allergens, intranasal corticosteroids, prior nasal surgery, saline nasal drops, topical decongestants and oral decongestants. Despite this treatment, the patient continued to suffer from symptoms. Per American Academy of Otolaryngology practice guidelines, surgical intervention with ethmoidectomy is indicated. The literature does support improvement in health outcome.

On the other hand, the code 30117 representing intranasal lesion destruction via Vivaer is considered experimental at this time. Current peer reviewed literature is limited to industry sponsored case series and no prospective randomized trials. As such, this treatment modality is not proven to be as effective as traditional methods of treatment. The literature does not support improvement in health outcome.

The 31254 procedure is likely to be more beneficial than any other existing standard health service.

The 30117 procedure is not likely to be more beneficial than any other existing standard health service.

The patient has been treated with antibiotics, antihistamine/decongestant combination, antihistamines, avoidance of allergens, intranasal corticosteroids, prior nasal surgery, saline nasal drops, topical decongestants and oral decongestants. Despite this treatment, the patient continued to suffer from symptoms. Per American Academy of Otolaryngology practice guidelines, surgical intervention with ethmoidectomy is indicated. However, even though Vivaer is FDA (Food and Drug Administration) for this indication, the treatment is not supported in the literature at this time.

The adverse risks do not increase over standard treatment/services.

The carrier's denial of overage for: 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 should be modified to overturn code 31254 and uphold code 30117.