Is endoscopic sinus surgery (ESS) with procedures 30520 and 30140 medically necessary for a patient with deviated nasal septum and chronic rhinitis, given the lack of recent CT results and failed treatment within the last 12 months?

DECISION: NOT MEDICALLY NECESSARY

This request for septoplasty (30520) and inferior turbinate reduction (30140) does NOT meet medical necessity criteria because the patient lacks both a recent CT scan (within 12 months) and documented failed conservative treatment within the appropriate timeframe.

Critical Missing Requirements

Lack of Recent Imaging

• The insurance criteria explicitly require a CT scan within the last 12 months, taken at the completion of medical therapy 1
• The most recent CT available is from several years ago, which is insufficient to document current disease severity or anatomical obstruction 1, 2
• The American Academy of Otolaryngology guidelines emphasize that objective evidence of disease must be current and documented after completion of appropriate medical management 3

Inadequate Documentation of Recent Conservative Treatment Failure

• The patient's conservative treatment (steroid nasal spray, antihistamine spray, saline irrigation) was attempted over 4 years ago, not within the required 12-month timeframe 1
• Insurance criteria mandate 6 weeks of saline irrigations, appropriate antibiotics if bacterial infection suspected, and 6 weeks of intranasal corticosteroids as recent failed treatment 1, 4
• The American Academy of Allergy, Asthma, and Immunology requires that maximal medical therapy be attempted immediately before surgical consideration, not years prior 1, 4

Specific Criteria Not Met

For Chronic Rhinosinusitis Without Polyps (CRSsNP)

• Requires chronic rhinosinusitis lasting longer than 12 continuous weeks with persistent symptoms after maximal medical treatment 1
• Must have objective evidence of disease by CT imaging showing obstruction and infection 1
• The CT must include detailed description of abnormal findings in each sinus, quantification of opacification extent, or Modified Lund-Mackay scoring 1

For Septoplasty Specifically

• The American Academy of Otolaryngology requires documented septal deviation causing continuous nasal airway obstruction that has not responded to at least 4 weeks of appropriate medical therapy 2
• There is no documentation of a recent 4-week trial of medical management for nasal obstruction 2
• Approximately 80% of the population has an off-center septum, but only 26% have clinically significant deviation requiring surgery 2

Required Next Steps Before Approval

Immediate Medical Management Trial

• Initiate or reinitiate intranasal corticosteroids for minimum 6 weeks 1, 4
• Implement regular saline irrigations for minimum 6 weeks 1, 4
• If bacterial infection suspected based on purulent drainage, prescribe appropriate antibiotics for 5-7 days minimum 1, 4
• Consider evaluation and treatment for allergic rhinitis given the chronic rhinitis diagnosis 4, 2

Obtain Current Imaging

• Order CT scan of paranasal sinuses AFTER completion of the above medical therapy trial 1
• The CT must document specific findings including degree of opacification, presence of obstruction, and anatomical details 1
• CT should use Modified Lund-Mackay scoring or similar quantification system 1

Documentation Requirements

• Document specific symptoms and their duration (must be >12 continuous weeks) 1
• Record compliance with medical therapy and specific response or lack thereof 1, 4
• Perform and document nasal endoscopy findings showing objective evidence of disease 3

Common Pitfalls to Avoid

• Do not approve surgery based on old imaging or remote treatment failures - the temporal relationship between failed medical management and surgical intervention is critical 1, 2
• Nasal congestion may be primarily due to allergic rhinitis rather than anatomical obstruction, which should be treated medically first 2
• The presence of inferior turbinate hypertrophy alone does not justify surgery without documented failure of medical management including intranasal corticosteroids 2, 5

Rationale for Denial

The 2025 American Academy of Otolaryngology guidelines are clear that endoscopic sinus surgery requires both current objective evidence of disease and recent failure of appropriate medical management 3. The insurance criteria appropriately align with these evidence-based standards 1. Proceeding to surgery without meeting these fundamental requirements would expose the patient to surgical risks (including bleeding, cerebrospinal fluid leak, orbital injury, septal perforation, and adhesions) without established medical necessity 3, 6, 7.