Is sinus surgery medically indicated for a 19-year-old male with chronic sinusitis, possible deviated septal deviation or septal spurring, and inadequate response to medical management, including nasal steroids and antibiotics?

Medical Necessity Assessment for Sinus Surgery in Chronic Maxillary Sinusitis

Direct Recommendation

Sinus surgery (endoscopic sinus surgery) is medically indicated for this 19-year-old male with chronic maxillary sinusitis who has failed appropriate medical management, including antibiotics, nasal steroids, and saline irrigations, with objective evidence of extensive sinusitis on CT and inflammatory changes on endoscopy. 1

However, septoplasty specifically is NOT medically indicated at this time because there is no documented evidence of septal deviation or septal spurring causing nasal obstruction. 2 The MCG criteria explicitly require "nasal septal deviation or septal spurring" to be present for septoplasty approval, and the clinical documentation states it is "unclear" if these anatomical findings exist. 2

Algorithmic Approach to This Case

Step 1: Verify Chronic Rhinosinusitis Diagnosis

• This patient meets diagnostic criteria for chronic rhinosinusitis without nasal polyps (CRSsNP): presence of at least 2 cardinal symptoms (nasal drainage, congestion, facial pressure) for >12 weeks, plus objective evidence on CT and endoscopy. 1, 3
• The diagnosis of J32.0 chronic maxillary sinusitis with extensive CT changes and inflammatory findings on endoscopy confirms the disease. 1

Step 2: Assess Adequacy of Medical Management

• Medical management has been appropriate and adequate: 1

  • Two courses of antibiotics including 3-week doxycycline course (long-term macrolide therapy equivalent) 1
  • Daily intranasal corticosteroids (nasal steroids) 1
  • Daily saline irrigations 1
  • Duration appears to exceed the 3-month threshold recommended before surgical consideration 1

• The patient has failed medical management: symptoms persist with patient feeling "miserable" despite compliance with first-line therapies. 1

Step 3: Determine Surgical Indication for CRS

• For moderate-to-severe CRS without nasal polyps that fails medical management after 3 months, CT evaluation and surgical work-up are warranted. 1
• The 2025 American Academy of Otolaryngology guidelines state that sinus surgery should be reserved for patients who do not satisfactorily respond to medical treatment, but in the majority of CRS patients, appropriate medical treatment is as effective as surgical treatment. 1
• This patient has both failed medical therapy AND has objective CT/endoscopic evidence supporting surgery. 1

Step 4: Address the Septoplasty Question

• The MCG criteria for septoplasty require ALL of the following: 2

  • Nasal septal deviation or septal spurring (NOT documented as present)
  • Inadequate response to medical management (present)
  • Symptoms of nasal obstruction interfering with lifestyle (present)

• Critical deficiency: No documented septal deviation or spurring. The clinical information explicitly states "it is unclear if he has a deviated septal deviation or septal spurring." 2

• Approximately 80% of the general population has some septal asymmetry, but only 26% have clinically significant deviation causing symptoms. 2 Without documented anatomical findings, septoplasty cannot be justified.

• If septal deviation exists but is not documented, obtain: 2

  • Specific description of septal deviation location (anterior vs posterior, degree of obstruction)
  • Objective physical examination findings with nasal endoscopy
  • Documentation that the deviation specifically obstructs the ostiomeatal complex or causes significant nasal airway obstruction

What IS Medically Indicated

Endoscopic sinus surgery (ESS) for chronic maxillary sinusitis is appropriate based on: 1

• Documented failure of comprehensive medical management including intranasal corticosteroids, saline lavage, and long-term antibiotic therapy 1
• CT scan showing extensive sinusitis changes 1
• Nasal endoscopy showing inflammatory changes 1
• Significant symptom burden affecting quality of life (patient "feels miserable") 1
• The 2007 EP3OS guidelines specifically recommend surgical work-up for CRS without nasal polyps when moderate-to-severe symptoms persist after 3 months of appropriate medical therapy 1

Functional endoscopic sinus surgery aims to surgically treat problem areas by ventilating the sinuses through natural ostia and addressing diseased sinuses. 4 Major outcomes research shows patients with CRS without polyps benefit from sinus surgery, with major complications occurring in less than 1% and revision surgery in approximately 10% within 3 years. 1

What Is NOT Medically Indicated

Septoplasty cannot be approved without documented anatomical findings. 2 The American Academy of Allergy, Asthma, and Immunology requires objective physical examination findings with specific description of septal deviation location and degree of obstruction to justify septoplasty. 2

Common Pitfalls to Avoid

• Do not confuse the need for sinus surgery with the need for septoplasty. These are separate procedures with different indications. 2, 5
• Do not assume all patients with CRS require septoplasty. Only those with documented septal deviation causing obstruction meet criteria. 2
• Do not proceed with septoplasty based solely on CT findings without clinical correlation. Physical examination must document the deviation and its functional impact. 2
• Anatomical variations are common but not always clinically significant. Only 26% of septal deviations cause symptoms requiring intervention. 2, 6

Required Documentation for Septoplasty Consideration

If septoplasty is to be considered in the future, the following must be documented: 2

• Specific location of septal deviation (anterior vs posterior, left vs right)
• Degree of obstruction caused by the deviation
• Correlation between the anatomical finding and the patient's nasal obstruction symptoms
• Nasal endoscopy findings clearly describing the septal pathology
• Evidence that the deviation specifically impacts the ostiomeatal complex or causes significant nasal valve obstruction

Recommendation Summary

Approve endoscopic sinus surgery for chronic maxillary sinusitis based on failed medical management and objective disease evidence. 1

Deny septoplasty at this time due to lack of documented septal deviation or spurring. 2 Request additional documentation of anatomical findings if septal pathology is suspected to exist but was not adequately documented in the initial submission.