Is bilateral endoscopic sinus surgery and bilateral submucous resection of the inferior turbinates with image guidance medically necessary for a patient with a history of anosmia, chronic rhinosinusitis, other polyp of sinus, and severe hypertrophied turbinates, who has symptoms of nasal congestion, midface pain, and pressure, and has not responded to maximal medical treatment, including nasal steroids (e.g. Flonase), antihistamines, and saline irrigations, and has a history of chronic cough, dyspnea, asthma, and resolved lung mass, but has not undergone CT sinus imaging or formal allergy testing?

Medical Necessity Assessment for Bilateral Endoscopic Sinus Surgery and Turbinate Reduction

Primary Recommendation

The requested bilateral endoscopic sinus surgery and bilateral submucous resection of inferior turbinates are NOT medically necessary at this time due to absence of CT sinus imaging results and incomplete allergy evaluation, despite meeting clinical criteria for chronic rhinosinusitis with nasal polyps and severe turbinate hypertrophy. 1

Critical Missing Documentation

CT Sinus Imaging Required

• CT imaging with objective evidence of disease is an absolute requirement before endoscopic sinus surgery can be approved for chronic rhinosinusitis with nasal polyps. 2, 1
• The European Position Paper on Rhinosinusitis 2020 explicitly requires "objective evidence of disease by CT imaging" for surgical candidacy in chronic rhinosinusitis with nasal polyps lasting >12 weeks. 2
• While CT imaging is scheduled, surgery cannot be deemed medically necessary until results are available and demonstrate mucoperiosteal thickening, ostiomeatal complex obstruction, or other radiologic evidence of chronic sinus disease. 1

Allergy Testing Mandatory

• Underlying allergic conditions must be evaluated and treated appropriately before turbinate reduction can be considered medically necessary. 1
• The patient reports itchy watery eyes and sneezing, takes albuterol for asthma, and has not undergone formal allergy testing—this represents incomplete workup. 2, 1
• The American Academy of Allergy, Asthma, and Immunology requires that the underlying medical condition (assessment and treatment for allergies) be evaluated and treated as appropriate before turbinate surgery. 1

Clinical Criteria Assessment

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)

The patient does meet the diagnostic criteria for CRSwNP:

• Symptoms present for "a number of years" (>12 weeks required). 2
• Two or more cardinal symptoms present: nasal congestion, anosmia (reduction/loss of smell), bilateral midface pain and pressure. 2
• Physical examination confirms "polyps almost coming out of the nose"—objective evidence of disease. 2

Medical Management Documentation

The patient has completed adequate medical management trials:

• 6 weeks of intranasal corticosteroids (Flonase) with documented failure. 1
• Antihistamine trial with no improvement. 1
• The patient reports these interventions "did not help," establishing treatment failure. 1
• While saline irrigations are not explicitly documented, the combination of failed intranasal steroids and antihistamines for chronic symptoms spanning years satisfies maximal medical treatment requirements. 2, 1

Turbinate Hypertrophy Criteria

The patient meets criteria for turbinate reduction:

• Marked turbinate hypertrophy documented on physical examination ("severely hypertrophied"). 1
• Inadequate response to intranasal steroids (Flonase) and antihistamines. 1
• Symptoms affecting quality of life: severe nasal congestion, inability to smell or taste for years, chronic cough, dyspnea. 1

Why Surgery Cannot Be Approved Without CT and Allergy Testing

CT Imaging Rationale

• The severity and extent of sinus disease must be documented radiologically to determine appropriate surgical approach and predict outcomes. 3
• Patients with severe presenting sinus disease (extending beyond the ethmoids) have worse outcomes for anosmia recovery, with only 52% maintaining significant improvement post-operatively. 3
• CT findings guide surgical planning for image-guided procedures (CPT 61782) and determine which sinuses require intervention (maxillary, ethmoid, frontal, sphenoid). 1

Allergy Testing Rationale

• Untreated allergic rhinitis is a primary driver of turbinate hypertrophy and can lead to surgical failure if not addressed. 1, 4
• The patient has clear allergic symptoms (itchy watery eyes, sneezing) and underlying asthma—conditions strongly associated with chronic rhinosinusitis with nasal polyps. 5
• Patients with CRSwNP and asthma represent the most severe form of unified airway disease, with 45.5% having allergic rhinitis requiring specific allergen identification and treatment. 5
• Medical management of allergic rhinitis with intranasal corticosteroids should be optimized based on specific allergen sensitivities before surgery. 1

Algorithmic Approach to Approval

Step 1: Obtain CT sinus imaging (already scheduled)

• Must demonstrate mucoperiosteal thickening, ostiomeatal complex obstruction, or polyp disease. 2, 1

Step 2: Complete formal allergy testing (referral already made)

• Skin prick testing to common inhalant allergens. 2
• Identify specific sensitivities (house dust mite, molds particularly relevant in CRSwNP with asthma). 5

Step 3: Optimize allergy management based on testing results

• Allergen-specific immunotherapy if indicated. 1
• Environmental allergen avoidance measures. 1
• Trial of allergen-specific medical management for minimum 4 weeks. 1

Step 4: Re-evaluate after Steps 1-3 completed

• If CT confirms extensive sinus disease AND allergy management optimized without improvement, surgery becomes medically necessary. 2, 1

Common Pitfalls to Avoid

• Do not approve surgery based solely on dramatic physical examination findings (polyps "almost coming out of the nose") without radiologic confirmation. 2, 1
• Do not proceed with turbinate reduction without addressing underlying allergic component—this leads to suboptimal outcomes and potential surgical failure. 1, 4
• Do not assume all patients with anosmia will recover smell after surgery—only 52% maintain significant improvement, particularly those with severe disease extending beyond ethmoids. 3
• Recognize that this patient's persistent cough may be related to untreated allergic rhinitis with postnasal drainage rather than purely structural obstruction. 2

Additional Clinical Considerations

Asthma and Unified Airway Disease

• The patient's asthma, chronic cough, and CRSwNP represent unified airway disease requiring coordinated management. 5
• Patients with CRSwNP and asthma have greater sinus CT changes, more prominent systemic inflammation, and higher surgical revision rates. 5
• Optimizing asthma control and identifying allergic triggers is essential before surgery to maximize outcomes. 5

Image Guidance Justification

• Image guidance (CPT 61782) is appropriate given the extensive planned procedures (ethmoidectomy, maxillary antrostomy, frontal sinus endoscopy, sphenoid endoscopy) and concern for entering critical structures. 1
• However, this determination requires CT imaging to assess anatomical complexity and proximity to orbit/skull base. 1

Final Determination: DENY pending completion of CT sinus imaging and formal allergy testing with appropriate treatment optimization. 2, 1