Is nasal/sinus endoscopy (31240) medically necessary for a 59-year-old female with recurrent sinus infections, deviated nasal septum, and hypertrophic turbinates, who has not responded to 4 rounds of antibiotics?

Medical Necessity Assessment for Nasal/Sinus Endoscopy (31240)

Nasal/sinus endoscopy (31240) is NOT medically necessary for this patient because she does not meet the established criteria for functional endoscopic sinus surgery (FESS), which requires chronic rhinosinusitis with nasal polyposis unresponsive to at least 1 month of medical treatment—a condition this patient does not have. 1

Critical Distinction: Recurrent Sinusitis vs. Chronic Rhinosinusitis

The patient presents with recurrent acute sinusitis (3 episodes this year), not chronic rhinosinusitis. 1 This is a fundamental distinction because:

• Chronic rhinosinusitis requires symptoms lasting >8-12 weeks continuously, including cardinal symptoms such as facial pain/pressure, purulent nasal drainage, nasal obstruction, and reduced sense of smell 1, 2
• Recurrent acute sinusitis consists of multiple discrete infectious episodes with symptom-free intervals between them 1
• The patient's presentation of "headaches between eyes all the time" with recurrent infections treated with antibiotics suggests episodic bacterial sinusitis, not the persistent inflammatory condition required for FESS 1

What This Patient Actually Needs

The appropriate procedures for this patient are septoplasty (30520) and bilateral inferior turbinate reduction (30140), NOT endoscopic sinus surgery. 1, 2 Here's why:

Septoplasty (30520) - MEDICALLY NECESSARY

The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that surgeons "should not endorse or require a predefined, one-size-fits-all regimen or duration of medical therapy as a prerequisite to sinus surgery." 2 This patient meets criteria because:

• Documented anatomical obstruction: CT confirms deviated nasal septum with hypertrophic inferior turbinates and bilateral concha bullosa 1
• Recurrent sinusitis attributed to septal deviation: The septal deviation obstructs the ostiomeatal complex, impairing sinus ventilation and drainage 1
• Failed appropriate therapy: 4 rounds of antibiotics for recurrent infections demonstrates treatment failure 1, 2
• Anterior septal deviation is more clinically significant than posterior deviation, affecting the nasal valve area responsible for >2/3 of airflow resistance 1

Bilateral Inferior Turbinate Reduction (30140) - MEDICALLY NECESSARY

Combined septoplasty with turbinate reduction is the correct surgical approach because compensatory turbinate hypertrophy commonly accompanies septal deviation, and the combined approach provides better long-term outcomes than septoplasty alone. 1, 3, 4

• CT demonstrates hypertrophic inferior turbinates, which represent compensatory hypertrophy on the side opposite the deviation 1, 4, 5
• Studies show the inferior turbinate on the concave side has significantly greater volume, including thickness of medial mucosa and conchal bone 4, 5
• Septoplasty combined with turbinate reduction results in less postoperative nasal obstruction compared to either procedure alone 1, 3

Nasal Endoscopy (31240) - NOT MEDICALLY NECESSARY

The MCG criteria for FESS require chronic rhinosinusitis with nasal polyposis that has not responded to ≥1 month of medical treatment. 1 This patient has:

• No documented nasal polyposis on CT scan 1
• No chronic rhinosinusitis (recurrent acute episodes are different) 1
• No evidence of persistent inflammatory disease requiring endoscopic intervention 1

The endoscopy code (31240) in this context appears to be for visualization during the concha bullosa reduction, which is an adjunctive technique during septoplasty/turbinate surgery, not a separate FESS procedure. 6

The Medical Management Controversy

The absence of documented intranasal corticosteroid therapy should NOT be a barrier to approval in this case. 2 Here's the nuanced reasoning:

• The 2025 American Academy of Otolaryngology guidelines specifically reject requiring "a predefined, one-size-fits-all regimen or duration of medical therapy as a prerequisite to sinus surgery" 2
• Anatomical obstruction from septal deviation is unlikely to resolve with medical management alone, making surgical intervention appropriate 2
• The guidelines recommend against prescribing antibiotics for chronic rhinosinusitis "if significant or persistent purulent nasal discharge is absent on examination" 2
• However, this patient has recurrent acute bacterial sinusitis (appropriate antibiotic use), not chronic rhinosinusitis 1, 2

Common Pitfall to Avoid

Do not confuse the medical management requirements for FESS (which requires failed intranasal corticosteroids) with those for septoplasty for anatomical obstruction. 1, 7, 2 While a 4-week trial of intranasal corticosteroids is recommended before septoplasty for simple nasal obstruction, the presence of recurrent sinusitis attributed to anatomical obstruction changes the clinical picture. 1, 2

Quality of Life Impact

The patient demonstrates significant functional impairment with:

• Recurrent infections requiring multiple antibiotic courses 1
• Persistent headaches affecting daily function 1
• Anatomical obstruction preventing adequate sinus drainage 1, 2

Septal deviation with obstruction significantly impacts quality of life, comparable to chronic heart failure in social functioning domains. 1

Final Recommendation

APPROVE: Septoplasty (30520) and bilateral inferior turbinate reduction (30140) DENY: Nasal/sinus endoscopy (31240) as a separate FESS procedure

The concha bullosa reduction can be performed via direct visualization during septoplasty without requiring a separate FESS authorization. 6 If the surgeon intends to use endoscopic visualization as a surgical technique during septoplasty (which is appropriate and improves outcomes), this is included in the septoplasty code, not billed separately as FESS. 8