Are CPTs 31040, 30930, and 31231 medically indicated for a patient with chronic rhinosinusitis and nasal obstruction despite maximal medical treatment, including Dupixent (dupilumab) and Xhance (fluticasone), with significant abnormalities on CT sinuses?

Medical Necessity Determination for CPTs 31040,30930, and 31231

Based on the submitted documentation, medical necessity IS SUPPORTED for endoscopic sinus surgery (CPT 31231) and septoplasty (CPT 30520, though not specifically queried), but medical necessity CANNOT BE DEFINITIVELY SUPPORTED for CPT 31040 (pterygomaxillary fossa surgery) or CPT 30930 (fracture nasal inferior turbinate) based on the clinical information provided.

Analysis by CPT Code

CPT 31231 (Nasal Endoscopy with Maxillary Antrostomy) - SUPPORTED

This procedure meets medical necessity criteria based on the following:

• Chronic rhinosinusitis duration exceeds 12 continuous weeks, with documented history spanning approximately 10 years and recent exacerbation despite biologic therapy 1

• Failed maximal medical treatment including:

  • Dupilumab (biologic therapy) every 2 weeks for several months 2
  • Xhance (intranasal corticosteroid) twice daily 1
  • Saline rinses 1
  • Multiple courses of systemic steroids (twice yearly) 1
  • Antibiotics for acute exacerbations 1

• Objective evidence of disease on CT imaging showing left maxillary sinus mucus retention cyst or polyp, moderate ethmoid mucosal thickening, and opacification of ostiomeatal units 1

• Endoscopic findings demonstrate bilateral polyps wrapping around middle turbinates, occluding 50-70% of airway above inferior turbinate 1

• Patient meets criteria for difficult-to-treat rhinosinusitis defined as persistent symptoms despite appropriate treatment including surgery (patient had 3 prior surgeries) and maximal medical therapy 1

CPT 30520 (Septoplasty) - LIKELY SUPPORTED (though not specifically queried)

• Septal deviation causing continuous nasal airway obstruction is documented in the clinical context 1
• Failed appropriate medical therapy for more than 4 weeks (patient has been on treatment for months to years) 1
• Common pitfall avoided: While septal deviation is present in 80% of the general population, this patient has documented nasal breathing difficulty and failed medical management, distinguishing clinically significant deviation from incidental anatomic variation 3

CPT 31040 (Pterygomaxillary Fossa Surgery) - NOT SUPPORTED

Medical necessity cannot be established because:

• No appropriate Clinical Policy Bulletin exists for this procedure code per the documentation provided
• No specific indication documented for pterygomaxillary fossa involvement (no mention of masses, tumors, or pathology requiring access to this anatomic region) 1
• Standard endoscopic sinus surgery for CRSwNP does not routinely require pterygomaxillary fossa access 1
• The CT findings and clinical presentation describe typical CRSwNP without extension requiring this approach 1

CPT 30930 (Fracture Nasal Inferior Turbinate) - NOT SUPPORTED

Medical necessity cannot be established because:

• No appropriate Clinical Policy Bulletin found per documentation
• Does not meet MCG criteria for biopsy/resection procedures (no mass or lesion of turbinates documented) 1
• While turbinate reduction may be performed as part of comprehensive sinus surgery, fracture technique specifically is not indicated by the clinical findings presented 1
• The primary pathology is polyps wrapping around middle turbinates, not inferior turbinate hypertrophy requiring fracture 1

Critical Clinical Context Supporting Surgery

Evidence of Biologic Therapy Failure

Despite Dupilumab treatment (the highest-level therapy for CRSwNP), this patient demonstrates:

• Persistent bilateral polyps on endoscopy 2
• Very poor sense of smell 2
• Constant anterior and posterior nasal drainage 2
• Continued need for systemic steroids twice yearly 2

This is significant because dupilumab has been shown in high-quality trials (LIBERTY NP SINUS-24 and SINUS-52) to reduce nasal polyp scores by 1.80-2.06 points and significantly improve symptoms in most patients 2. Failure to respond adequately to dupilumab indicates severe, refractory disease 4, 5.

Historical Pattern of Rapid Recurrence

• Three surgeries in one year approximately 10 years ago with rapid polyp regrowth following each 1
• This pattern suggests aggressive disease biology requiring both surgical and ongoing medical management 6

Progression Despite Escalating Medical Therapy

• Initially treated with Nucala (mepolizumab) for eosinophilic CRSwNP 1
• Switched to Dupilumab due to persistent bilateral polyps despite Nucala 2
• Even with Dupilumab, polyps persist at 50-70% airway obstruction 1

Rationale for Medical Necessity

The patient meets EPOS 2020 criteria for surgical intervention:

• Chronic rhinosinusitis with nasal polyps lasting >12 weeks 1
• Failed appropriate medical therapy including intranasal corticosteroids (6+ weeks), saline irrigations, antibiotics when indicated, and biologic therapy 1
• Objective evidence on CT scan showing sinus disease 1
• Endoscopic evidence of significant polyp burden causing obstruction 1
• Classified as "difficult-to-treat rhinosinusitis" - persistent symptoms despite adequate surgery (3 prior procedures), intranasal corticosteroids, and biologic therapy 1

The patient meets Aetna Clinical Policy Bulletin 0937 criteria:

• Chronic rhinosinusitis >12 continuous weeks 1
• Failed maximal medical treatment including >6 weeks saline irrigations, >6 weeks intranasal corticosteroids, and antibiotics for bacterial infection 1
• Objective evidence of disease by CT imaging 1

Important Caveats and Considerations

Biologic Therapy Timing

• Current guidelines suggest biologics should be optimized before proceeding to revision surgery in patients with prior surgical failure 5, 6
• However, this patient has been on Dupilumab with persistent disease, suggesting either inadequate duration or true biologic failure 7
• Optimal duration of biologic trial before declaring failure: Studies show maximal benefit typically achieved by 6-12 months 4
• Documentation should clarify total duration of Dupilumab therapy to ensure adequate trial (started in the month referenced but specific duration unclear)

Surgery as Adjunct to Biologic Therapy

• Surgery and biologics are not mutually exclusive - many patients require both for optimal control 5, 6
• Post-operative continuation of Dupilumab may improve long-term outcomes and reduce recurrence risk 4
• The presence of metallic plates from prior surgery may complicate revision procedures 1

Documentation Gaps

While medical necessity is supported for endoscopic sinus surgery, the following would strengthen the case:

• Exact duration of Dupilumab therapy (documentation states "every 2 weeks" but start date relative to current evaluation unclear) 7
• Quantification of symptom severity using validated instruments (SNOT-22 scores would be ideal, as dupilumab trials used this outcome) 2, 4
• Specific documentation of compliance with all medical therapies 3
• Allergy testing results if not already performed, given the integrated airway disease 1

Surgical Planning Considerations

• Given history of rapid recurrence, extended/complete ethmoidectomy with maxillary antrostomy and sphenoidotomy may be more appropriate than limited procedures 1
• Continuation of biologic therapy post-operatively should be planned to reduce recurrence risk 4, 6
• Patient should be counseled about realistic expectations given prior surgical failures and aggressive disease pattern 5

Summary of Medical Necessity by CPT

CPT Code	Procedure	Medical Necessity	Rationale
31231	Nasal endoscopy with maxillary antrostomy	SUPPORTED	Meets criteria for CRSwNP with failed maximal medical therapy including biologics, >12 weeks duration, objective CT findings, significant endoscopic disease [1,2]
30520	Septoplasty	LIKELY SUPPORTED	Septal deviation with nasal obstruction, failed medical therapy >4 weeks [1,3]
31040	Pterygomaxillary fossa surgery	NOT SUPPORTED	No documented indication for pterygomaxillary fossa access; no mass, tumor, or pathology requiring this approach [1]
30930	Fracture nasal inferior turbinate	NOT SUPPORTED	Does not meet MCG criteria; primary pathology is middle turbinate polyps, not inferior turbinate hypertrophy requiring fracture [1]