Is balloon sinuplasty medically necessary for a patient with chronic sinusitis and no documented Modified Lund-Mackay Scoring System?

Medical Necessity Determination for Balloon Sinuplasty

Balloon sinuplasty (CPT 31295,31298) is NOT medically necessary for this patient because the insurance criteria require documentation of the Modified Lund-Mackay Scoring System or specific quantification of sinus opacification in the CT report, which is absent in this case, despite the patient otherwise meeting all clinical criteria for the procedure. 1

Critical Missing Documentation

The insurance policy explicitly states that CT documentation "must include which sinus has the disease and the extent of disease including the percent of opacification or the use of a scale such as the Modified Lund-Mackay Scoring System." 1 The current CT report describes:

• Partial opacification of ethmoid sinuses bilaterally
• Minimal mucosal thickening of sphenoid sinuses
• Minimal nodular mucosal thickening of right maxillary sinus
• Left frontal sinus mucosal thickening with fluid accumulation

However, no Modified Lund-Mackay score is documented, and no specific percentage of opacification is provided for any sinus. 1

Clinical Appropriateness vs. Administrative Requirements

Patient Meets Clinical Criteria

From a purely clinical standpoint, this patient demonstrates appropriate indications for sinus intervention:

• Symptom duration >12 weeks with nasal obstruction, facial pain/pressure, and purulent drainage 1, 2
• Failed maximal medical therapy including two antibiotics, nasal steroid spray, antihistamine spray, saline irrigation, and allergy evaluation with immunotherapy 1, 3
• Abnormal endoscopic findings showing bilateral inferior turbinate hypertrophy, middle turbinate edema, and mucous in middle meatus bilaterally 1
• CT evidence of disease with mucoperiosteal thickening, air-fluid levels, and opacification 1

Balloon Sinuplasty May Be Inappropriate Regardless

Even if documentation requirements were met, balloon sinuplasty alone may not be the optimal surgical approach for this patient. 1 The 2025 American Academy of Otolaryngology-Head and Neck Surgery guidelines specifically state that when sinuses involve certain features, "the surgeon should perform sinus surgery that includes full exposure of the sinus cavity (lumen) and removal of diseased tissue, not just balloon or manual ostial dilation." 1

This patient has concerning features:

• Bilateral turbinate hypertrophy requiring more than ostial dilation 4
• Bilateral middle turbinate edema suggesting more extensive disease 1
• Multiple sinus involvement (frontal, ethmoid, maxillary, sphenoid) with mucoperiosteal thickening 1
• Air-fluid levels indicating active infection requiring comprehensive drainage 1

Balloon sinuplasty is most effective for limited chronic rhinosinusitis without nasal polyposis (CRSsNP) affecting primarily the frontal, sphenoid, and maxillary sinuses—not for patients with extensive ethmoid disease or significant turbinate pathology. 3, 5

Common Pitfalls to Avoid

Pitfall 1: Inadequate CT Documentation

The most common reason for denial is failure to include Modified Lund-Mackay scoring or specific opacification percentages in the radiology report. 1, 2 The CT must be obtained within 12 months and after completion of medical therapy. 1

Pitfall 2: Performing Balloon Sinuplasty for Advanced Disease

Using balloon sinuplasty alone when more comprehensive endoscopic sinus surgery is indicated leads to inadequate treatment and need for revision surgery. 1, 4 The 2025 guidelines emphasize that extent of surgery should match disease severity, not be limited by procedural choice. 1

Pitfall 3: Ignoring Anatomic Obstruction

This patient has bilateral turbinate hypertrophy and middle turbinate edema that may require turbinate reduction or other structural correction beyond what balloon dilation provides. 4 Focusing solely on ostial dilation without addressing anatomic contributors leads to persistent symptoms. 4

Recommended Path Forward

Option 1: Obtain Proper CT Documentation

Request a formal Modified Lund-Mackay score from the radiologist or have the surgeon document specific percentages of opacification for each affected sinus. 1, 2 This would satisfy the insurance requirement if balloon sinuplasty is deemed clinically appropriate.

Option 2: Consider Comprehensive Endoscopic Sinus Surgery

Given the extent of disease involving multiple sinuses with mucoperiosteal thickening, bilateral turbinate hypertrophy, and middle turbinate edema, comprehensive endoscopic sinus surgery (ESS) with turbinate reduction may be more appropriate than balloon sinuplasty alone. 1, 4 The 2025 guidelines support full exposure and removal of diseased tissue for patients with these features. 1

Option 3: Hybrid Approach

Balloon sinuplasty can be performed adjunctively with traditional ESS techniques for the ethmoid sinuses and turbinate reduction. 3 This addresses both the ostial obstruction in the frontal/maxillary/sphenoid sinuses and the more extensive disease in the ethmoid complex. 3

Quality of Life and Outcome Considerations

While balloon sinuplasty shows significant improvement in SNOT-20 scores for appropriately selected patients with limited disease, prolonged medical management trials actually worsen patient symptoms and quality of life. 6, 5 This patient has already undergone extensive medical therapy for >12 weeks without benefit. 6

However, performing an inadequate surgical procedure (balloon sinuplasty alone for extensive disease) may provide only temporary relief and necessitate revision surgery, further delaying definitive treatment and prolonging patient suffering. 1, 4 The goal should be to perform the appropriate extent of surgery the first time based on disease characteristics. 1