Is the requested ear cartilage graft (21235) and removal of ear canal lesion(s) (69145) medically necessary for a patient with a papilloma in the left ear canal?

Medical Necessity Assessment for Ear Canal Lesion Excision with Possible Cartilage Graft

The requested procedures (CPT 69145 - removal of ear canal lesion and CPT 21235 - ear cartilage graft) are medically necessary for this 19-year-old patient with a symptomatic ear canal papilloma causing complete canal occlusion, recurrent infection, and functional impairment.

Primary Indication: Symptomatic Ear Canal Papilloma

• Papillomas of the ear canal require surgical excision due to their potential for local destruction, high recurrence rates, and risk of malignant transformation 1
• The patient's complete ear canal occlusion with associated pressure, fullness, and infectious complications represents significant functional impairment requiring intervention 1
• Surgical removal is the treatment of choice for ear canal papillomas, as medical management (antibiotics) only addresses secondary infection but not the underlying lesion 1

Justification for Lesion Excision (CPT 69145)

• Manual removal of ear canal lesions is indicated when the lesion causes complete canal occlusion, recurrent infection, or functional impairment 2
• The patient's history of drainage requiring antibiotics indicates infectious complications from the obstructing mass 2
• Normal audiometric testing (250-8000Hz with excellent word recognition) confirms that hearing preservation is achievable and should be prioritized during surgical intervention 2

Justification for Cartilage Graft (CPT 21235)

Cartilage grafting may be necessary following excision of ear canal lesions when:

• The surgical defect requires structural support to prevent canal stenosis or collapse 3, 4
• Reconstruction is needed to maintain canal patency and prevent recurrent obstruction 4
• Ear cartilage autografts (conchal, tragal, or scaphal) provide excellent structural support with minimal donor-site morbidity 3

Evidence Supporting Cartilage Graft Safety

• Ear cartilage harvest demonstrates favorable safety profile with early complications limited to hematoma (6.7%) and sensory impairment (3.3%) 3
• Long-term sensory impairment occurs in only 12.9% of cases and is confined to conchal donor sites 3
• The procedure is considered relatively safe with favorable aesthetic outcomes and minimal functional impact 3, 4

Clinical Decision Algorithm

The surgeon should determine cartilage graft necessity based on:

1. Extent of lesion excision: If removal creates a defect >50% of canal circumference or involves cartilaginous canal wall, grafting is indicated 4
2. Risk of canal stenosis: Anterior or circumferential defects have higher stenosis risk requiring structural support 4
3. Intraoperative assessment: Final decision on grafting should be made after visualizing the post-excision defect 3, 4

Common Pitfalls to Avoid

• Incomplete excision of papilloma increases recurrence risk - ensure clear margins while preserving hearing structures 1
• Failure to plan for potential cartilage harvest - consent patient preoperatively for possible graft even if uncertain 3
• Inadequate follow-up after papilloma excision - surveillance is critical as recurrence may occur early or late, and malignant transformation can develop 1
• Overlooking infectious complications - the patient's history of drainage and antibiotic response indicates secondary infection that must be addressed perioperatively 2

Alignment with Coverage Criteria

The MCG guideline for Head and Neck Surgery (SG-HNS) indicates surgery is covered for "other pathology of eye, head, or neck" and "drainage or debridement procedure needed" for "other head and neck pathology requiring drainage or debridement"